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COPYRIGHT DEPOSIT 



Postmortem Pathology 



A MANUAL OF THE TECHNIC OF POST-MORTEM EXAMI- 
NATIONS AND THE INTERPRETATIONS 
TO BE DRAWN THEREFROM 

A PRACTICAL TREATISE FOR STUDENTS AND PRACTITIONERS 



BY 

HENRY W. CATTELL, A.M., M.D. 

PRESIDENT OF THE PHILADELPHIA MEDICAL JURISPRUDENCE SOCIETY, I905-6 ', SOMETIME PATHOLOGIST 

TO THE PHILADELPHIA, PRESBYTERIAN, AND PENNSYLVANIA HOSPITALS ; AMERICAN 

EDITOR AND TRANSLATOR OF ZIEGLER'S SPECIAL PATHOLOGY ; 

FELLOW OF THE COLLEGE OF PHYSICIANS 

OF PHILADELPHIA, ETC. 



THIRD EDITION 



COPIOUSLY ILLUSTRATED WITH COLORED PLATES AND FIGURES 



" Rotto dal mento insin dove si trulla. 
Tra le gambe pendevan le minugia ; 

La corata pareva, e il tristo sacco 

Che merda fa di quel che si trangugla." 

—Dante 



PHILADELPHIA AND LONDON 

B. LIPPINCOTT COMPANY 

1906 



K ftS ! 



LIBRARY of CONGRESS 

One 0»o> Received 

OCi 13 1906 

CLASS k AXc. No. 



Copyright, 1903, by J. B. Lippincott Company 



Copyright, 1905, by J. B. Lippincott Company 



Copyright, 1906, by J. B. Lippincott Company 



PRINTED BY J. B. LIPPINCOTT COMPANY. PHILADELPHIA, U. 6. A 






TO THE MEMORY OF 
MY FRIENDS 

DR. THOMAS G. MORTON 

WHOSE SURGICAL SKILL AND GREAT DIAGNOSTIC ACUMEN WAS AT THE 
SERVICE OF ALL DURING A LONG AND BUSY LIFE 



DR. THOMAS S. KIRKBRIDE, JR., 

WHOSE EARLY DEATH WAS A SAD LOSS TO AMERICAN 
PATHOLOGY 



/ 




PREFACE TO THE THIRD EDITION 

¥¥ 

This book has been out of print during the past school year owing 
to the unexpectedly rapid exhaustion of the second edition, within 
sh months of its publication in 1905, and to the difficulties incident 
to seeing the work through the press because of unavoidable labor 
disturbances now adjusted. This delay, however, has afforded the 
author opportunity for making the revision more thorough. Two short 
chapteis, one upon " Plant Pathology" and the other upon the " Teach- 
ing of Post-Mortem Technic," have been added and also much recent 
matter bearing upon syphilis, tuberculosis, tropical diseases, and other 
topics of immediate interest to those making post-mortem examina- 
tions. The number of illustrations has been increased by nineteen 
and several of the old cuts have been replaced by new ones. 

The writer is indebted to Dr. W. M. L. Coplin for facilities con- 
ceded him for making special dissections for photographs at the 
Philadelphia Hospital and to Dr. W. Reynolds Wilson and Dr. George 
M. Boyd for a similar courtesy at the Philadelphia Lying-in Charity 
Hospital. The author is also under obligations to many kind friends 
for assistance; especially to Dr. John Guiteras, of Havana, and Dr. 
Martha Tracy, of New York, for material used in the chapter upon 
" Diseases due to Parasites;" to Dr. J. Morgan Coffin for information 
regarding the performance of autopsies in the United States Army, 
Navy, and Marine-Hospital Service; to Dr. R. V. Lavenson and Dr 
G. O. Jarvis, both of Philadelphia, for some suggestions introduced 
into Chapters VI and X; to Mr. John Starr Hewitt for seeing the 
book through the press; to Miss L. A. Brown for the preparation of 
the Index ; and to the writers of those suggestive reviews of the second 
edition, appearing in Science, May 19, 1905, by Professor Lewellys F. 
Barker, of Johns Hopkins University, and in the Munchener medicin- 
ische Wochenschrift, April 4, 1905, by the late Professor Hans 
Schmaus, of Munich. 

As a German edition of this book will soon be issued by J. F. Berg- 
mann, of Wiesbaden, the writer would be indebted for any sugges- 
tions and criticisms having especially in view the introduction into 
its pages of the most approved American and English methods of 
post-mortem teclinic and of the latest results of original research in 
pathology now so actively and successfully carried on in America, 
Canada, and Great Britain. 

HENRY W. CATTELL, M D 

3709 Spruce Street, Philadelphia, Pa., July 1, 1906. 

iii 



PREFACE TO THE FIRST EDITION 

¥¥ 

This book has been written for those who ought to make autopsies 
but do not and for those of whom such investigations are required, as 
medical students, hospital interns, and Coroner's physicians. While 
the author has mainly relied upon his personal experiences in the prep- 
aration of the subject-matter of this manual, he has freely used classi- 
fications and material derived from Orth's Pathologisch-anatomische 
Diagnostik, Osler's Practice of Medicine, Nauwerck's Sections- 
Technik, and other publications mentioned in the foot-notes and in the 
text. He is, therefore, much indebted to these authorities, as well as 
to Dr. George Robinson and Mr. Louis Schmidt for most of the 
drawings, all of which were prepared under the writer's direction, to 
his friends and former students Drs. William S. Wadsworth, Mary 
E. Lapham, E. D. Burkhard, and Edward Lodholz for sugges- 
tions in the preparation of the book, and to that excellent proof-reader 
Mr. T. Grow Taylor for seeing the work through the press. 

HENRY W. CATTELL, M.D. 

3709 Spruce Street, Philadelphia, Pa., March 31, 1903. 



CONTENTS 

¥¥ 

CHAPTER PAGE 

I. General Considerations i 

II. Order of Examination and Post-mortem Records 14 

III. Post-mortem Instruments and How to Use them 34 

IV. Care of the Hands and Treatment of Post-mortem Wounds 45 

V. Examination of the Exterior of the Body 53 

VI. Technic of Opening the Abdominal Cavity and Topographic 

Examination of its Walls and the Parts contained therein. . 89 
VII. Technic of Exposing the Thoracic Cavity and the Examination 

of the Parts contained therein 103 

VIII. Diseases of the Heart, Blood, Blood-vessels, and Lymph -vessels . . 126 

IX. Diseases of the Respiratory Tract and Accessory Parts 156 

X. Critical Examination of the Organs of the Abdominal Cavity . . 173 

XI. Diseases of the Genito-Urinary Tract 209 

XII. Diseases of the Liver, Pancreas, and their Ducts 223 

XIII. Examination of the Skull and Brain 235 

XIV. Spinal Column, Spinal Cord, and Nerves 253 

XV. Diseases of the Brain, Spinal Cord, and Nerves 257 

XVI. Examination of Nasopharynx, Eyes, and Ears 270 

XVII. Bones and Joints 275 

XVIII. Post-mortem Examination of the New-born 289 

XIX. Restricted Post-mortem Examinations 295 

XX. Restoration and Preservation of the Body 298 

XXI. Diseases due to Parasites 306 

XXII. Preservation of Tissues for Microscopic and Macroscopic Purposes 368 

XXIII. Bacteriologic Investigations 382 

XXIV. Weights and Measurements 394 

XXV. Post-mortem Examinations of the Lower Animals 407 

XXVI. Plant Pathology 432 

XXVII. Teaching of Post-mortem Technic and the Interpretations to 

be Drawn from the Material so obtained 434 

XXVIII. Medicolegal Suggestions 436 

XXIX. Prussian Regulations for the Performance of Autopsies in Medi- 
colegal Cases 479 

XXX. Usual Causes of Death: Their Nomenclature, Complications, 

and Synonyms . . 49* 

XXXI. References 508 

vii 



LIST OF ILLUSTRATIONS 

¥¥ 

PLATE PAGE 

I. Outline Chart of Human Body Second page of cover 

11. Normal Size of Familiar Objects 2^ 

III. Post-Mortem Haemoglobin Scale. Moisture Scale Third page of cover 

IV. Chart of Tumors 148 

V. Bacteriologic Chart 385 

VI. Powder Markings 449 

FIG. PAGE 

1. Portable post-mortem table to 

2. Body in coffin prepared for post-mortem examination 10-11 

3. Post-mortem table for babe, constructed of chairs and drawing-board. . 10-11 

4. Post-mortem room of Ayer Clinical Laboratory, Pennsylvania Hos- 

pital io-ii 

5. Refrigerator box for preservation of bodies 11 

6~8. Working plans for preparing refrigerator box for storage of bodies ... 12 
9. Adjustable and movable table for transporting bodies 12 

10, 1 1. Plans for post-mortem table 12-13 

12, 13. Combination electric, gas, and water fixtures for post-mortem table . . 13 

14. Section- or cartilage-knife 34 

15. Cartilage-knife with projection on back 34 

16. Post-mortem knife with a faulty point and improper belly 34 

17. Coplin's brain-knife 34 

18. Bread-knife for incising large organs 34 

19. Valentine's knife 34 

20. Pick's myelotome 34 

21. Forceps; saw; needles; hammer; steel tape measure; hone and strop; 

and scalpel 34~35 

2.2.. Saw for post-mortem work 34~35 

23. Butcher's saw for post-mortem work 34~~35 

24. Hey's saw 34~~35 

25. Metacarpal saw 34~35 

26. Luer's double rhachiotome 34~35 

ix 



x LIST OF ILLUSTRATIONS 

FIG. PAGE 

27. Masland's electric saw and stand 35 

28-30. Various forms of scissors 35 

31, 32. Proper and improper forms of enterotome 35 

33. Proper form of costotome 36 

34. Improper form of costotome 36 

35. Steel hammer 36 

36-38. Various forms of chisels 36-37 

39, 40. Various forms of forceps 3°~37 

41. Straight grooved director 36 - 37 

42-44. Various forms of Satterthwaite's calvarium clamp 36~37 

45. Folding head-rest 37 

46. Cornell folding clamp 38 

47. Measuring stick 38 

48. Raspatory 38 

49. Pocket-case of instruments 38 

50. Cones for measuring orifices 38~39 

51. Glass balls for measuring orifices 38~39 

52. Linen twine wrapped of proper length ready for use 38~39 

53. Formad's pocket-case for post-mortem instruments 38~39 

54. Method of holding cartilage-knife 39 

55-57. Lines showing methods for opening thoracic and abdominal cavities . . 89 

58, 59. Method of making initial incision over sternum 89 

60, 61. Method of removing skin over sternum and ribs 89-90 

62. Method of opening abdominal cavity 89-90 

63. Method of incising ribs 89-90 

64. 65. Method of separating sternoclavicular attachment 90 

66. Incising first rib and sternoclavicular articulation with costotome 104 

67. Severance of diaphragm 104 

68. 69. Removal of bony parts covering thoracic cavity 104-105 

70. Breastplate after its removal from body 104-105 

71. Methods of enlarging abdominal cavity and of protecting operator's 

hands from injury 104-105 

72. Organs of the mediastinum 105 

73. Method of opening pericardium no 

74. Cardiac plexus and ganglion of Wrisberg , no 

75. Pericardium opened in 

76-78. Lines for opening heart 114 

79. Method of opening right auricle 116 

80. Situation of pulmonary veins 1 16 

81. Method of opening left ventricle 116-117 

82. Method of removing heart from body 116-117 

83. Method of opening pulmonary artery 116-117 



LIST OF ILLUSTRATIONS x i 

FIG. PAGE 

84. Interior of left auricle and ventricle fully exposed 117 

85. Reconstruction of heart after its examination 117 

86-89. Method of opening lung and examining pulmonary vessels 122-123 

90. Method of removing tongue, oesophagus, trachea, etc., in a single piece . . 124 

91. Examination of organs of neck 124-125 

92. Method of opening trachea posteriorly 124-125 

93. Examination of trachea and vocal cords 124-125 

94. " Grand swipe" of thoracic organs 125 

95. Finger method of tying intestine 179 

96. Method of tying intestines preparatory to their removal 180 

97. Bucket method of opening and cleansing intestines 180 

98. Method of removing small intestines 180-181 

99. Opening of small intestines after their removal from the body 180-181 

100. Method of incising kidney with its ureter still attached 180-181 

101, 102. Method of opening kidney 180-181 

103. Method of removing capsule of kidney (without gloves) 181 

104. Method of removing capsule of kidney (with gloves) 181 

105. Relations of pancreas, kidney, ureter, adrenal, and solar plexus 192 

106. Position for body in examination of rectovaginal region 194 

107-114. Post-mortem extirpation of bladder, uterus, and adnexa through 

vagina, and subsequent restoration of parts 194-195 

115. Method of opening uterus 194 

116. Uterus and adnexa after being opened 195 

117-119. Author's method of examining testicles, epididymis, spermatic cord, 

etc., without disfigurement 194-195 

120. Method of opening seminal vesicles 195 

121. Relation of gall-ducts and pancreas to the duodenum 195 

122. Examination of bile ducts , 198 

123. Method of examining stomach 199 

124. Removal of liver from body 199 

125. Method of incising liver 205 

126. Starting-point of incision in removal of brain 236 

127. Parting of hair so as not to injure it in removal of brain 236 

128. Toilet of hair preparatory to removal of brain in the female 236-237 

129. Method of sawing skullcap 236-237 

130. Angular method of removing brain 236-237 

131. Method of breaking up inner table with an old knife after sawing 237 

132. Method of drawing off skullcap with a retractor 237 

133. Appearance of dura mater after removal of calvarium 238 

134. French method of opening skull 238 

135. French method of opening dura 239 

136. Appearance of brain after removal of dura 238-239 



xii LIST OF ILLUSTRATIONS 

FIG. PAGE 

137. Method of removing brain from skull 238-239 

138. Sawing of brain 239 

139. Removal of pituitary body 244 

140. Nerves and foramina 244-245 

141-144. Virchow's method of dissecting brain 244-245 

145-147. Virchow's method of dissecting brain (continued) 246-247 

148. Nauwerck's method of dissecting brain 246-247 

149. Basal ganglia, with cerebellum, pons Varolii, and medulla oblongata 

attached, in Meynert's method of dissecting brain 246-247 

150. Flechsig's, Brissaud's, and Dejerine's transverse sectioning of brain .... 247 

151. Dejerine's incisions for brain previous to hardening 247 

152. Lines for removing spinal cord and brain, the latter through a small 

triangular occipital incision 252 

I 53~ I 58- Removal of spinal cord 252-253 

159. Opening spinal cord 253 

160. Method of examining nasopharynx, eyes, and ears 270 

161. 162. Harke's method of examining nasopharynx 270 

163. Use of wire-saw in examining auditory apparatus 273 

164. Postmortem on child 290 

165. Johan van Neck's painting of Frederik Ruysch, the anatomist 290-291 

166. Relative size of spleen, kidney, and appendix in a new-born child 290 

167. Examination of ductus arteriosus 290-291 

168. Examination of umbilical vessels 290-291 

169. Removal of spinal cord in a child 291 

170. 171. Method of examining the femur for syphilitic osteochondritis 292 

172. Method of exposing Beclard's centre 293 

173, 174. Method of examining nasal cavities, antrum of Highmore, etc 298 

J 75» ^76- Method of sewing up the body 298-299 

177. Slee's method of fixing skullcap 299 

178. Author's method of holding skullcap in place 300 

179. Method of withdrawing blood from a body previous to injection of 

embalming fluid 298-299 

180. Injection of body with embalming fluid 298-299 

181. 182. Refrigerating room for preservation of bodies, University of 

Pennsylvania , 299 

183. Method of determining rectal temperature in a guinea-pig 390 



184 
185 
186 
187 
188 



Animal holder , . ■ 390 

Method of performing peritoneal injection in a rabbit 390-391 

Ear method of inoculating rabbit 390-391 

Post-mortem examination of guinea-pig 390-391 

Post-mortem examination of rabbit 391 



189-191. Post-mortem examination of horse 411, 412, 414 



LIST OF ILLUSTRATIONS xiii 

FIG. PAGE 

192. Lines for opening cephalic cavities of horse 420 

193. Lines for opening cranial cavity of horse 421 

194. Lines for exposing cranial and nasal cavities in ruminants 424 

195. Appearance of cranial cavity in a cow 424 

196. 197. Second method for removal of the brain in ruminants 425 

198. Post-mortem examination of sheep 426 

199. Post-mortem examination of dog 427 

200. Exposure of oral and pharyngeal cavities in a dog 428 

201. Virchow, 1892, Jubilee Medal 479 

202. Jars prepared for medicolegal work 487 



POST-MORTEM EXAMINATIONS 

CHAPTER I 

GENERAL CONSIDERATIONS 

Historical. — No mention is made in literature before the time 
of Herophilus (320-250 B.C.) of opening the dead body for legal 
or scientific purposes, although ancient writings abound in refer- 
ences to violent death and the shedding of blood. Long before this, 
however, the Jewish priests are known to have examined the carcasses 
of animals killed for food to detect impurities, and the knowledge of 
anatomy displayed by the ancient Egyptians in embalming could only 
have been acquired by dissection. 

The old and important office of Coroner 1 dates from the reign of 
King Athelstan (925 a.d.). Its duties were clearly defined soon 
after the Norman conquest, and from England the institution was 
brought to America by the colonists. (Becker.) Massachusetts in 
1877 abolished the office of Coroner, substituting therefor medical 
examiners, and in 1904 the New York Legislature passed a bill with 
the same object in view for New York City, which was, however, 
returned to the Governor with the Mayor's veto. In 1905 a similar 
bill failed to pass the Legislature. In Pennsylvania the office of Cor- 
oner is a constitutional one. 

The first post-mortem examination in the Western Hemisphere 
appears to have been made in 1535 at Montreal during the prevalence 
of an unknown epidemic disease. On this occasion the body of one 
Philip Rougemont 2 was " ripped to see if by any meanes possible we 
might know what it [the disease] was, and to seeke meanes to save 
and preserve the rest of the company." The heart, liver, lungs, 
spleen, and thigh were examined. Among other early autopsies in 
America may be mentioned one in which death was due to a fracture 

1 Wellington's King's Coroner (1905) and Smith's Manual for Coroners 
(1904) give some useful information upon this subject, especially concerning 
the English Coroner's Act of 1887. 

* Richard Hakluyt's Voiages, 1589, vol. iii, p. 226; 1904, vol. viii, p. 247. 



2 POST-MORTEM EXAMINATIONS 

of the skull (1639) and another in which a man died from a bullet 
wound (1643). 1 

Definition. — A postmortem, autopsy, or necropsy is the sys- 
tematic exposure and critical examination of the cadaver or carcass 
with the object of determining the cause of death or of studying mor- 
bid conditions in any of their various aspects. Other synonyms em- 
ployed are necroscopy, mortopsy, section, sectio cadaveris, sectio 
anatomica, and post (colloquial). The German word Obduction 
means properly a medicolegal postmortem, which differs from an 
ordinary postmortem only in that the information thereby obtained is 
applied to furthering the ends of justice. The word " autopsy" was 
first used in the sense now generally accepted by v. Ruhl, Crighton, 
and Bluhm, in their account of the examination of the body of the 
Empress Maria Feodorowna, of Russia. 2 

Purpose. — As the object of a post-mortem examination is the 
acquisition of exact data, the procedure should be carried out in a 
scientific and systematic manner. This is especially important in 
medicolegal cases, which frequently involve not only the reputation 
and liberty, but even the life of a human being. If the examination 
be performed in a perfunctory or desultory manner, some detail of 
the greatest importance may be overlooked, and the information 
obtained may be so insufficient as to be practically valueless for 
statistic or demonstrative purposes. In no other department of 
medical science are greater demands made upon the faculties of obser- 
vation and discrimination, and in none other are sound knowledge 
and accurate work so indispensable. As the science of medicine 
advances, new discoveries necessitate a constant revision of the 
statistics of even the most common diseases. While it would seem 
to be quite needless to urge upon a physician the importance of per- 
forming post-mortem examinations, it is a fact that extremely few 
are made outside of hospitals, and even there necropsies are too 
frequently conducted without the supervision of a trained pathologist. 
It cannot be questioned, however, that the practitioner of medicine 
who improves his opportunities for pathologic study on the cadaver 

1 Hoadley, Proceedings Conn. Med. Soc., 1892, pp. 207-17, quoted by Steiner, 
Johns Hopkins Bull., August, 1903. See also Packard, Proceedings Phil. Path. 
Soc, January 1, 1900, p. 45; Editorial, Jr. Amer. Med. Assoc, October 28, 1893, 
p. 661. 

2 Salzb. med.-chir. Ztg., 1829, vol. i, p. 107; Foster's Encyclopedic Med. Diet., 
vol. i, p. 516, quoting from Kraus's Kritisch-etymologisches medicinisches Lexikon. 



GENERAL CONSIDERATIONS 3 

will be a better diagnostician and safer therapist, will have a more 
enduring reputation, and will receive a greater pecuniary return than 
he who neglects such means of investigating morbid processes. 

Opportunities for the study of physiologic structures offered by 
postmortems upon presumably healthy individuals killed by accident 
should not be neglected, as thorough familiarity with the normal 
appearance of the various organs and tissues is necessary to a recogni- 
tion of morbid changes or slight variations from health. Such sub- 
jects also often afford favorable opportunities for the study of the 
earliest manifestations of disease, particularly of tumors and the 
infective granulomata. New anomalies also may be found, and these, 
as in the case of polydactylism, may be studied in order to support or 
disprove Mendel's and Galton's * laws of inheritance, etc. 

Autopsies present exceptional opportunities for reviewing the 
study of anatomy or for investigating such subjects as anastomoses 
after amputation. They may also be employed for acquiring dexterity 
in surgical manipulations. To this end, it is permissible in suitable 
cases to practise surgical operations that entail no visible disfigure- 
ment of the body. Some of the more recently introduced procedures, 
such as decapsulation of the kidney, mechanical irritation of the 
hepatic peritoneum, transplantation of ovarian tissue, Lorenz's opera- 
tion for congenital dislocation of the hip, Gersuny's injection of 
paraffin for the correction of deformities, Quincke's lumbar puncture, 
suturing a wound of the heart, total enucleation of the prostate, etc., 
will at once suggest themselves in this connection. 

Permission. — When a postmortem is desired, the first step in 
every instance is to secure the legal right to make it, either by order 
from a regularly-appointed officer of the law, or by consent (preferably 
written) from the next of kin to the deceased, or, in the absence of 
relatives, from the person in charge of the funeral. The feelings of 
relatives and friends must be fully respected; scientific zeal is no 
excuse for wounding them. In a suit for damages brought a few 
years ago against a Philadelphia hospital which had allowed a post- 
mortem to be made without the consent of the nearest relative, the 
Judge severely censured the institution for holding the autopsy, but 
held that no damages could be recovered, as the hospital was a chari- 
table institution. 

1 Natural Inheritance, i88q. 



4 POST-MORTEM EXAMINATIONS 

The method to be pursued in gaining permission for the perform- 
ance of an autopsy will depend largely upon circumstances, but tact 
will nearly always overcome sentimental objections and secure consent 
except when refused on account of religious scruples. 1 Thus, one 
resident in a hospital will obtain the opportunity for making a post- 
mortem examination upon almost every patient dying in the wards 
during his term of service, while another interne of the same institu- 
tion will, for one reason or another, meet refusal in the great majority 
of his cases. Permission may often be obtained by arousing the 
curiosity of the relatives and friends, or by the humane plea that no 
harm will be done to the dead while possibly much good to the living 
may result. The author recalls a case in which those interested 
expressed great satisfaction on learning that death was not due to 
consumption, which had been diagnosed during life. An invitation 
to a member of the family to be present at the postmortem or a 
promise to make a death-mask (see page 305) will often secure the 
desired permission. The laity should be encouraged to ask for an 
autopsy. A carefully performed postmortem often secures ready con- 
sent to, or even a voluntary request for, others in the vicinity in which 
the physician resides. The blank forms which accompany insurance 
papers often contain the query, "Was an autopsy made?" and an 
affirmative answer greatly strengthens the holder's claim. Indeed, 
insurance companies should encourage the making of autopsies, as it 
is to their own pecuniary advantage so to do. Our Boards of Health, 
with their enormous power for good or evil, in some States have the 
legal right to compel the performance of postmortems, a prerogative 
that has already been advocated more warmly by the lay press than 
by the profession at large. Among the indigent foreigners who are 
so numerous in our large cities, the offer of a small sum of money 
will often secure permission to make a necropsy, but a threat to refer 
the case to the Coroner unless permission is voluntarily granted should 
never be employed. Undertakers who oppose the making of autopsies 
should not be recommended. 

The pecuniary value that dead bodies may have sometimes gives 
rise to legal contests. The Supreme Court of California has decided 
that one cannot dispose of his own corpse by will. A man bequeathed 



1 See Lancet, January 13, 1906, p. 109, in regard to the attitude of the public 
towards post-mortem examinations. 



GENERAL CONSIDERATIONS 5 

his body to the managers of a medical college, in the hospital of which 
he had been treated, to be used for scientific purposes. The man's 
relatives claimed the cadaver, and applied to the courts for an injunc- 
tion restraining the medical college from using it. The kinsfolk won, 
the Court holding that the custody of the corpse and the right of 
burial belong to the next of kin. 1 There are in America and in 
France several societies the members of which sign cards granting 
permission for the performance of postmortems on their bodies; 
in view of the above decision the card should be endorsed by the 
legal heirs, except in such States as New York, where Section 305 of 
the Penal Code provides that a person may dispose by will of his 
corpse as he may direct. Even when permission has been given 
circumstances may prevent an autopsy, as in the case of Phillips 
Brooks, who was a member of the American Anthropometric Society. 
The Prosector of the Society, on reaching Boston from Philadelphia, 
could not perform the postmortem, as death had been caused by diph- 
theria and the body had already been placed in an hermetically sealed 
coffin, in order that a public funeral might be held. 

In the case of Loesch vs. the Union Casualty and Surety Com- 
pany, 2 the Supreme Court of Missouri held that the making of the 
autopsy without previous notice to the Company was no bar to 
recovery. The physician making the examination and the mother of 
the deceased, who tacitly assented to its performance, were in ignorance 
of the clause in the policy providing that if a postmortem were held 
without due notice to the Company in time to have its medical adviser 
present, all claims under the policy should be forfeited. As soon as 
the error was discovered, which was in time for a re-examination, the 
Company was notified. 

There should be a law permitting post-mortem examinations of 
the bodies of all persons dying in charitable institutions. Such a rule 
exists in the hospitals in Germany, and this custom prevailed for some 
time in the Philadelphia Hospital with practically no opposition, until 
lawsuits, arising out of this custom, caused it to be discontinued. 
In cadavers allotted to the Anatomical Board, care should be taken 
not to destroy the arteries commonly used for injection. If in the 
course of an autopsy conditions are found which indicate foul play, 



Amer. Med., April 6, 1901, p. 37. 

Jr. Amer. Med. Assoc., September 26, 1903, p. 



6 POST-MORTEM EXAMINATIONS 

as serious traumatic injuries or the signs of a poison in toxic doses, the 
examination should be immediately suspended, and steps at once taken 
to have the Coroner or other legal officer take charge of the case ; but 
if properly authorized by the Coroner or his legal representative, the 
examination may proceed in the manner prescribed for conducting 
medicolegal postmortems. 

When portions of the body are desired for future study or for 
preservation, permission to remove them should be obtained from 
some one connected with the household, though not necessarily from 
the nearest relative ; it is, of course, unnecessary to tell how much is to 
be taken away! Should the person authorizing the autopsy forbid 
the removal of any portion of the body from the house, no 
specimens should be taken. Consent can nearly always be obtained 
for the removal of small pieces of tissue for microscopic purposes, 
even when permission to take away larger specimens is refused. 1 
In the necropsy on the body of President McKinley, the bullet which 
produced the fatal wound was not found, because a member of the 
family objected, though without legal right, to the search, and it was 
only with the greatest difficulty that consent was obtained to remove 
portions of the body for microscopic study. In France the law for- 
bids the extraction in legal cases of teeth post mortem without special 
administrative authorization. (Letulle.) The careless handling of 
specimens removed at autopsies, especially those containing patho- 
genic organisms, as well as the culture of the more virulent bacteria 
in our laboratories, are sources of danger to the public that will no 
doubt evoke legislative restrictions in the near future. For the pro- 
tection of their patients, residents on duty in the surgical and gynaeco- 
logical wards of our hospitals should be forbidden to make or even to 
be present at autopsies. 

Those Present. — To one who makes many autopsies, a capable 
assistant and a trained attendant are invaluable. Knowing their 
duties, they anticipate what is required of them. In order to famil- 
iarize an assistant with a proper method of procedure, it is a good 
plan, except in important cases, for the experienced pathologist to 
play at times the part of an assistant by permitting the learner to 
perform the autopsy. Professional friends, especially those who saw 

'In the case of Winkler vs. Hawkes the Supreme Court of Iowa held that 
consent for an autopsy being given, permission is implied for removal of the organs 
for microscopic study, if such be necessary to effect the purpose of the postmortem. 



GENERAL CONSIDERATIONS y 

the patient during life, should be invited to be present at the autopsy; 
the scrutiny of critical eyes undoubtedly ensures more careful work. 
Besides, in medicolegal cases the responsibility of making an autopsy 
in which the evidence obtained may be sufficient to convict a person 
of the gravest of crimes is often too great to be borne alone. Before 
work is begun, the relatives and friends should be tactfully requested 
to withdraw from the sight, smells, and sounds of the postmortem. 
The nurse should be within calling distance, and the undertaker or 
his assistant should remain, as he can often render valuable aid. 
While those present are prone to give advice that is useless, the sug- 
gestions made by them are frequently of great value. Courtesy 
demands that a guest should not be too forward in offering advice, 
but should always be ready to render such assistance as the operator 
may need or request, for the one making the autopsy is in command 
and is alone responsible for the success or failure of the work entrusted 
to him. The desire of those present to handle the specimens is natural, 
though this should not be done until the notes have been dictated and 
portions removed for microscopic study. While witnessing the per- 
formance of a score or more of postmortems in Vienna during the 
summer of 1905, the writer was greatly impressed with the difficulty 
of securing a proper interpretation of the morbid lesions present with- 
out handling the specimens himself. Letulle lays great stress upon 
the prohibition of smoking during the performance of the postmortem. 
Time. — The time allowed to elapse after death before making an 
autopsy depends upon the circumstances of the case, and may vary 
from a few minutes to several days or even months. The examina- 
tion should never be deferred longer than is absolutely necessary, 
as the entire cadaver is soon invaded by bacteria, and nuclear figures 
and cellular elements quickly lose much of their value for microscopic 
study. But the feeling of warmth imparted to the hands of the 
operator while making a necropsy soon after death, especially where 
there is much elevation of the temperature of the cadaver, as in fatal 
cases of heat-exhaustion or atropine poisoning, is so repugnant to 
one's sensibilities that sufficient time should always be allowed for the 
temperature of the corpse to fall to a point inconsistent with suspended 
animation. In New York State a postmortem must immediately fol- 
low a legal electrocution; it is popularly believed that in at least one 
case the criminal was not killed by the electric current. The suit 
brought in the case of Bishop, the so-called mind-reader and cataleptic, 



8 POST-MORTEM EXAMINATIONS 

where the necropsy was made immediately after death, will also be 
recalled. The law in Germany is that at least twenty-four hours 
should elapse between death and the autopsy. 

The time required for the completion of a postmortem depends, 
of course, upon the conditions under which it is performed, upon the 
nature of the case, and upon the skill of the operator. Under favor- 
able circumstances the author has removed the brain in less than 
three minutes from the time of making the preliminary incision, and 
has made an entire post-mortem examination, including the removal 
of the cord, in less than nineteen minutes. On the other hand, eight 
hours of uninterrupted work have been consumed by him in the per- 
formance of one autopsy. In a hospital the time usually allowed for 
a necropsy is about an hour and a half. Virchow considered that 
three hours' work was ordinarily sufficient to complete a medicolegal 
postmortem according to the Prussian regulations given in Chapter 
XXIX, and that in certain cases this time might be reduced by one- 
third. It is stated that Rokitansky 1 performed over thirty thousand 
autopsies, which would average scarcely an hour each. Kolisko, of 
Vienna, sometimes made five or six postmortems in a morning, and the 
author himself has more than once performed ten within twenty-four 
hours. Owing to lack of time, the surgeon or clinician may wish the 
necropsy to be made with more celerity than is consistent with thor- 
oughness. As he often merely desires to ascertain a certain fact or to 
observe a single organ, he can generally be immediately accommodated, 
and the examination may be afterwards completed in the routine man- 
ner. The performance of the autopsy may take but a short time in com- 
parison with that required for the proper preparation and study of 
the tissues. Indeed, the collection and preservation of material for 
future investigation by the microscopist, chemist, experimentalist, and 
bacteriologist are often the most important parts of the process, for 
an error made at the postmortem may be irremediable later on. As 
Virchow aptly said, " A postmortem does not admit of repetition, 
whereas in a clinical examination at the bedside any omission may 
ordinarily be rectified at a subsequent visit." 

Place. — The place at which a post-mortem examination is to be 
made is rarely a matter of choice, especially in private practice, but 

1 Preface to the Sydenham Society's translation of Carl Freiherr von Roki- 
tansky's Pathologische Anatomic 



GENERAL CONSIDERATIONS 



9 



it should always be where the best light is obtainable. Daylight from 
the- north, such as is sought by artists, should be preferred. If the 
autopsy must be made after dark, a combination of the electric and 
Welsbach lights is the most satisfactory artificial illuminant Orth 
states that a good substitute for daylight may be obtained by allowing 
the artificial light to pass through a glass flask containing water 
slightly colored with methylen blue. Such a flask may be used also 
as a condenser to concentrate the rays of light upon the surface under 
examination. In Manchester, England, where the days are so often 
dark, textile workers adopt various expedients to get true color 
values ; one of these consists in having the artificial light pass through 
specially colored glass. That one should accustom himself to the 
changes of color produced by different kinds of artificial light was 
well shown in one of the author's autopsies made by gaslight on a 
subject of poisoning by battery-fluid: the tissues stained with potas- 
sium bichromate presented an entirely different appearance when 
examined by daylight the next morning. 

Time and labor will, of course, be spared by making the autopsy 
before the body is dressed for interment, and the undertaker should 
be directed to defer embalming it until after the completion of the 
examination. The fact that the appearance of the exposed parts is 
improved by the loss of blood and by its gravitation into the larger 
cavities of the body as a consequence of the section may be indeed 
mentioned to him as an argument in favor of the procedure. For- 
tunately, the formalin injecting-fluid now generally employed for 
embalming purposes does not interfere with the microscopic study of 
tissues as did the arsenical preparation formerly used. Indeed, one 
of the special methods for hardening the brain is based on its previous 
injection with formalin by means of a cannula introduced through 
the orbit or nasal cavities. 

The amount of preparation necessary for an autopsy will depend 
somewhat on whether the examination is to be made (I ) in a private 
house or at an undertaker's establishment, or (II ) in a hospital or 
morgue. 

I. In the former case a table on which to lay the cadaver is rarely 
available, and a substitute must be provided. There are in the market 
several portable operating-tables 1 which may be used for this purpose, 

1 Sherman, Amer. Med., October 26, 1901, p. 644. Illustration from Internat. 
Clinics, 1902, vol. 1, Twelfth series. 



IO POST-MORTEM EXAMINATIONS 

as the one shown in Fig. i. The postmortem may be performed 
while the body lies in the coffin, on the coffin-lid, or, still better, on 
the bottom of the inverted coffin, on the wooden slab usually found 
in the box, or on a door taken from its hinges and placed upon two 
kitchen chairs. The undertaker may have prepared the corpse for 
the autopsy, as seen in Fig. 2. For the body of a child the marble 
top of a bureau or wash-stand placed on the backs of chairs may 
be used. (Fig. 3.) 

To facilitate the necessary manipulations, the cadaver must lie at a 
proper height. If placed too low, fatiguing work in the stooping posi- 
tion is necessitated. A piece of oil-cloth, mackintosh, or old carpet 
should be placed under the table or its substitute, to prevent soiling the 
floor. In addition to the articles brought by the operator (see page 42), 
two buckets half filled with lukewarm water, an empty basin, and 
several newspapers should be provided. 

Scrupulous cleanliness in the performance of an autopsy is of the 
greatest importance. The reasons for this are apparent. We owe it 
to our fellow-men to leave no malignant organisms in the place where 
the postmortem was performed. Besides, the pathologist can see 
better and his sense of touch is finer if the organs, fingers, and rubber 
gloves are not besmeared. 

If the operator be careful not to soil his own person, the surround- 
ing objects will be more likely to escape contamination. For this 
reason, he may accustom himself in private work to make necropsies 
in non-contagious cases with but little protection to his clothing. In 
France the usual dress consists of a hospital blouse, overalls of home- 
spun, an apron reaching to the feet, and a pair of sabots or wooden 
shoes. In our hospitals the regulation duck trousers, shirt-sleeves, 
bare arms, rubber gloves, and an apron are most frequently seen. 
There should be a bountiful supply of water, a basin for the hands, 
and a board on which to arrange the instruments. The parts under 
examination should be cleansed as occasion requires by a stream of 
water squeezed from a sponge, the sponge itself not being permitted 
to touch the tissues. Mucous and serous surfaces should always be 
carefully inspected before washing. 

In private work the laity are likely to estimate the skill of the 
pathologist by the neatness displayed in sewing up the body and 
the appearance of the room after the autopsy is completed. The 
greatest care should be exercised that no blood-stains be left behind. 




Fig. 2. — Body in a coffin prepared for a post-mortem examination. In this case the board supporting the body 
is elevated by means of a soap-box, there being no ratchets or pins to support the body as are so often 

found in modern ice-boxes. 




Fig. 3. — Post-mortem table for a babe, constructed of chairs and a drawing-board ; the marble slab from a wash- 
stand or bureau may be used for the same purpose. 




0) <u 



_ o 



"18 



GENERAL CONSIDERATIONS H 

Incense or cascarilla may be burned or ground coffee strewn on red-hot 
coals to remove the odor from the apartment, which should then be 
thoroughly aired. 

II. In a hospital or morgue the facilities for making postmortems 
are much more complete. The room set apart for this purpose should 
be clean, well lighted, and secure against intrusion. The author re- 
members once having seen, much to his annoyance, a number of con- 
valescents in the grounds of a hospital watching the performance of 
an autopsy through an open window. If practicable, the dead-house 
should communicate by an underground passage with all the wards of 
the hospital, and a covered or screened court for the undertaker's 
wagon should also be provided. A well-appointed mortuary room, 
like the one at the Ayer Clinical Laboratory of the Pennsylvania 
Hospital (Fig. 4), should have a refrigerator box with scales so 
arranged that bodies can be weighed within it. At the author's sug- 
gestion, the Fairbanks Scale Company fitted one of their scales to a 
Ridgeway refrigerator for this laboratory (Fig. 5), in such a way 
that the cadaver could be weighed while in the ice-chest and the result 
noted without opening the doors. (For structural plans see Figs. 
6, 7, and 8.) The corpse should be weighed as soon as it is brought 
into the dead-house, as it will usually be found to lose weight after 
a time. Each box should have two doors, one opening into the post- 
mortem room, and the other into a waiting-room on the opposite side, 
through which the body may be viewed by friends and removed by 
the undertaker. This arrangement also prevents the transmission of 
noises and odors. In case there are several tiers, the ingenious device 
in use in the Massachusetts General Hospital may be employed 
(Fig. 9). The waiting-room ought also to be so arranged that 
religious services may be held in it, if desired. 

The operating-table should be strongly built, about seven feet long, 
two feet nine inches high, and three feet six inches wide. The top 
may be of slate, soapstone, zinc, or copper; its surface should slope 
gently towards a central perforated depression connected with a drain 
and a ventilating shaft operated by an electric fan, and should be pro- 
vided with sunken grooves converging towards the centre. (Figs. 
10 and 11.) The drains of the post-mortem room should not connect 
with those of the hospital, but empty directly into the main sewer. An 
ideal though expensive plan would be to sterilize all the waste water. 
A scale of feet, inches, and fractional parts of an inch (or of centi- 



12 



POST-MORTEM EXAMINATIONS 



metres) should be laid off on the top of the table, or, if this be of 
slate, upon a metal rule sunk into it in such a way that no edges are 
exposed. For class instruction, a revolving table is required, prefer- 
ably one upon which by an ingenious fulcrum and lever attachment 
the body can be weighed. An extra iron table like those used in the 
dissecting-room may be provided, in case it is desired to conduct two 
autopsies at once. The making of several necropsies simultaneously 
was discontinued in one Philadelphia hospital owing to the fact that 




Fig. 9. — Movable table for transporting bodies, in use at the morgue of the Clinico-pathological Lab- 
oratory of the Massachusetts General Hospital. The top may be elevated or depressed to a level of the 
upper or lower tiers of the ice-chest or the table upon which the post-mortem examination is to be made. 
Designed by Mr. Francis Blake; Drawn from a photograph by L. S. Brown ; Illustration secured through 
the kindness of Drs. Mallory and Wright. 

three livers were found in a body subsequently exhumed on account 
of suspected poisoning. Additional tables, upon which to place 
instruments, scales, plates, and other requisites, should also be at hand. 

Ample illumination should be provided by a northern skylight, if 
possible, by day, and by a combination gaslight and electric-light fix- 
ture directly over the table (Figs. 12 and 13) by night. A good 
modification of the greenish blue Peter Cooper Hewitt light was shown 
during December, 1905, at the New York Electrical Exhibition in 
Madison Square Garden. In strength it is said to exceed the 




Fig. 6. — Working plans for preparing refrigerator with eight compartments for the storage of 
bodies preparatory to their removal for burial. Front view. 





Fig. 7. — Ground plan for a truck, 
a, guide; b, track. 



Fig. 8. — Cross-section. 



GENERAL CONSIDERATIONS I3 

ordinary electric light twenty-five fold and not to cause any dis- 
comfort to the eyes. Kronig and Siedentopf * recommend a shaft 
of reflected light from a lantern outside of the room projected through 
an opening in the wall so that it strikes a mirror in the ceiling 
above and is reflected down upon the table. By this device speci- 
mens may be photographed in situ. Plenty of water, hot and cold, 
should be supplied by means of an overhead spigot with rubber tubing 
attached, so that by the use of a mixer a steady stream of water at 
any required temperature may at once be had wherever directed. 

To support the head there should be a solid block or rest similar 
to those used by undertakers. This block should be about forty 
centimetres long, twenty centimetres high, ten centimetres broad, and 
hollowed out on top to receive the nape of the neck. For children 
smaller sizes are employed. (See Figs. 58, 126, 127, and 128.) 

A board upon which the viscera may be placed after their 
removal, for convenience in making sections, etc., should also be at 
hand, as the table top becomes slippery from exuded fluid and the 
organs are held with difficulty while being incised. It is the custom 
abroad to set a stool upon which instruments are arranged over the 
upper end of the thighs within easy reach of the operator. To avoid 
the spattering of dripping fluids when opening the cranium, a piece of 
previously moistened horse-blanket or a mop may be placed on the floor 
beneath the head. The operator, if subject to rheumatism, should 
stand on a piece of dry board rather than on the cement or tile floor 
usually found in mortuaries. The latticed wood flooring found on 
ships is well adapted to this purpose. The lavatories should preferably 
be the surgical kind operated by the feet or the elbows. All linen, 
towels, etc., used in the dead-house ought to bear some distinguish- 
ing mark, and should be put at once into a proper disinfectant, or 
sterilized apart from the other wash of the hospital. 

A desk for the post-mortem book, a revolving chair, a slop-sink, 
a wash-stand, several cabinets, a work-table supplied with ordinary 
chemicals, a bacteriologic outfit, preservative fluids, and apparatus for 
preparing frozen sections complete the furniture of a well-equipped 
mortuary. Frozen sections add greatly to the interest and value of 
an autopsy by enabling the operator to compare the microscopic and 
macroscopic appearances of a part while it is still in a fresh state. 
A library and a museum should be attached to the dead-house. 

1 Arch. f. klin. Chir., 1904, vol. lxxiv, no. 2, p. 373. 



CHAPTER II 

ORDER OF EXAMINATION AND POST-MORTEM RECORDS 

As precision, supplemented by a simple, cleanly technic, is the key- 
note for a successful autopsy, the following rules should govern the 
removal and opening of organs at every post-mortem examination 
when it is possible so to do. 

I. Never disturb any part or organ until its position relative to 
adjacent tissues and organs has been accurately determined. 

II. Never unnecessarily remove a part or organ if the proper in- 
spection of remaining parts or organs will thereby be rendered dif- 
ficult or impossible. 

III. When an organ is to be opened in order to examine its cavi- 
ties, walls, or component parts, the requisite incisions should be made 
in such a way as to permit, as far as possible, of the reconstruction 
of the organ in its original shape and condition. 

In the fulfilment of these conditions it is, therefore, best to begin 
by making a topographic examination of the contents of the cavity 
about to be explored. In the case of the trunk, the organs of the 
abdominal cavity are inspected first, those of the thorax next, and 
those of the pericardium last, whereas the removal of the organs and 
their minute description should be made in the reverse order. The 
abdomen should be examined before the thorax is opened, in order 
that the position of the diaphragm and the relative situations of the 
various abdominal organs can be determined before the entrance of 
air into the relaxed thoracic walls has altered the normal relationship, 
before the heart has been emptied of its blood by cutting the abdominal 
veins, and before the escape of blood and other liquids has obscured 
the appearances of the parts under consideration. 

In order that nothing of importance shall be overlooked, the 
pathologist should have a definite plan of survey that he follows at 
every autopsy. The following order of examination is recommended : * 

I. Inspection of the exterior of the body: (a) Signs of death; (b) Body- 
heat; (c) Hypostatic congestion; (d) Rigor mortis; (e) Build and nutrition; 

1 Virchow's routine method of performing a postmortem is given in Chapter 
XXIX. 

14 



ORDER OF POST-MORTEM EXAMINATION 



15 



(/) Anomalies; (g) Deformities, including scars; (h) Signs of trauma, includ- 
ing surgical wounds; (i) Signs of disease; (/) Skin; (k) Hair; (/) Eyes; 
(m) Nose; (m) Ears; (0) Mouth, including teeth; (/>) Nails; (q) Breasts; 
(r) Umbilicus ; ( s) External genitalia, including the vagina in the female ; 
(t) Anus; (u) Buttocks; (v) Other portions of the body. 

2. Topographic exploration of the abdominal cavity, 1 especial attention being 
directed to the situation of the organs contained therein, to the height of the 
diaphragm, to the peritoneum, to hernia, etc., and to the consideration of any 
modification to be made later on in the usual plan of procedure due to the pres- 
ence of pathologic lesions or of anomalies. 

3. Examination of the breasts (from behind); Mediastinum; Thymus; 
Thyroid ; Parathyroids ; Carotid glands ; Cervical and salivary glands ; Entrance 
of the thoracic duct into the subclavian vein. 

4. Topographic exploration of the pleural cavities. 2 

5. Pericardium and subserous adipose tissue ; Pneumogastrics ; Arch of the 
aorta ; Vena cava ; Cardiac plexuses. 

6. Heart (external and internal examination of each cavity in the direction 
of the blood-currents): (a) Papillary muscle; (b) Chordae tendineae; (c) Tra- 
becular; (d) Endocardium; (e) Valves; (f) Blood-vessels; (g) Lymphatics. 
Coronary arteries. 

7. Lungs: 3 (a) Pleura; (b) Lymph-glands; (c) Lobes; (d) Lobules; 

(e) Alveoli; (f) Bronchi; (g) Blood-vessels. Pulmonary vessels. Trachea. 
Larynx. 

8. Mouth and Pharynx : Tongue ; Palate ; Tonsils, etc. ; Epiglottis ; Exter- 
nal examination of the oesophagus. 

9. Omentum ; mesentery ; and other portions of the peritoneum, especial atten- 
tion being paid to enlarged glands. 

10. Spleen: (a) Capsule; (b) Follicles; (c) Pulp; (d) Trabecular; (e) Blood- 
vessels. 

11. Intestines (except the duodenum); Appendix vermiformis ; Rectum. 

12. Adrenal body: (a) Cortical substance; (b) Intermediary substances; 
(c) Medulla; (d) Vessels; (e) Nerves. Splanchnics. Semilunar ganglion. Kid- 
ney: (a) Capsule; (b) Cortex; (c) Medulla; (d) Pyramids; (e) Papilla; 

(f) Pelvis; (g) Blood-vessels. 

13. Ureters and bladder. 

14. In the male : Penis ; Urethra ; Scrotum ; Testicles ; Epididymis ; Prostate ; 
Spermatic cord ; Seminal vesicles, etc. In the female : Uterus ; Tubes ; Ovaries ; 
Broad ligaments ; Vessels ; Urethra, etc. 

15. Duodenum; Common duct, with its branches going to the liver and the 
pancreas. 



1 The organs are not incised at this time nor are their relations markedly 
disturbed. In the Rokitansky or Vienna technic the organs are incised as they 
are brought to the surface. 

2 While the heart is being examined time may be saved by having an assist- 
ant open the skull, as, theoretically, the heart should be exposed before the head 
is opened and the brain inspected before the heart is incised. 

s The pleural cavities, already superficially examined, are now to be more 
carefully inspected after the removal of each lung. 



I 6 POST-MORTEM EXAMINATIONS 

16. Stomach: (a) Mucosa; (b) Submucosa; (c) Muscularis; (d) Serosa. 
CEsophagus. 

17. Liver: (a) Capsule; (b) Acini; (c) Blood-vessels; (d) Bile-ducts. Gall- 
bladder. Portal vessels. 

18. Pancreas: (a) Acini; (b) Blood-vessels; (c) Smaller ramifications of 
the pancreatic duct; (d) Adjacent fat. Mesentery. 

19. Retroperitoneal glands; Diaphragm; Psoas muscle; Thoracic duct; 
Thoracic and abdominal aortas; Inferior vena cava; Abdominal sympathetics ; 
Abdominal portion of the spermatic duct, etc. 

20. Head: (1) Scalp; periosteum; and calvarium. (2) Meninges: (a) Dura; 
Longitudinal sinus; (b) Arachnoid; (c) Pia ; Pacchionian granulations; Basal 
sinuses; Vessels and Nerves; Cerebrum — (a) White and gray matter, (b) Blood- 
vessels; Ventricles; Pineal gland; Cerebral ganglia; Peduncles; Cerebellum; 
Pons; Medulla. (3) Pituitary body. (4) Eye. (5) Ear. (6) Nasopharyngeal 
cavities. (7) Salivary glands. (8) Region of face and neck. 

21. Vertebral column; Spinal cord and its membranes: 1 (a) White and gray 
matter; (b) Central canal; (c) Nerves; (d) Blood-vessels. 

22. Bones; Marrow ; Joints : (a) Fluid, (&) Blood-vessels. Peripheral nerves, 
Sympathetics, Lymph-nodes, Arterial trunks of the extremities, Muscles, Ten- 
dons, etc. 

23. Portions preserved. 

24. Bacteriologic, photographic, microscopic, chemic, and physiologic exam- 
inations. 2 

As a general rule, the order above suggested will be found con- 
venient and practical. It must, of necessity, be subject to more or less 
variation, depending on the circumstances of the case. For example, 
in a medicolegal necropsy it is often advantageous to examine the seat 
of the suspected fatal lesion at once, and afterwards resume the order 
given above as nearly as possible. Thus, after death by poison the 
abdominal cavity is immediately inspected, while in a case of gunshot 
wound of the head the cephalic cavity is first investigated. The 
finding of anomalies, malformations, adhesions, etc., or the necessity 
of undertaking special lines of investigation may also cause a de- 
parture from the ordinary procedure. Thus, in autopsies on the re- 
mains of those who have died from nervous diseases it is often best 
to remove the brain and cord before opening the body. 

The same order of examination as that given above may be followed 
out with advantage in the case of postmortems upon the lower animals. 
In Chapter XXV, devoted to the discussion of this subject, the order 
of procedure recommended by Kitt will be found. 

1 For sake of cleanliness the spinal cord may often best be removed first at 
an autopsy. 

2 Should the case subsequently be published, due reference to this fact should 
be made upon the notes. 



ORDER OF POST-MORTEM EXAMINATION 17 

Letulle advises, as a routine practice, that the thoracic and abdom- 
inal organs be removed en masse from the body, and first examined 
from their posterior aspect, as follows : x 

(1) Large, or right, and small, or left lower, azygos veins. (2) Thoracic duct 
(dissection). (3) Suprarenal glands (dissection and removal). (4) Ureters (dis- 
section). (5) Kidneys and their pelves (dissection and removal). (6) Thoraco- 
abdominal aorta (opened). (7) Inferior vena cava (opened). (8) Main portion 
of the portal vein and its branches of origin. (9) Common bile duct and its two 
canals of origin. (10) Pancreas (dissection of posterior surface, tail, and borders). 
(11) Removal of the thoracico-abdominal aorta. (12) Dissection of the oesophagus 
to its point of entrance into the stomach. (13) Organs of mouth and pharynx: 
(a) incision of the pharynx; (b) dissection of the velum palati; (c) tonsils; (d) 
tongue; (<?) sublingual glands. (14) Incision of the oesophagus at its point of 
origin. (15) Epiglottis and larynx (examination and opening). (16) Trachea and 
primitive bronchi. (17) Pulmonary roots (examination). (18) Lymphatic glands 
of the posterior region of the body (deep cervical, posterior mediastinal, diaphrag- 
matic, prelumbar, retrorectal). (19) Cervicothoracic portion of the pneumogastric 



After the posterior examination is completed, the parts are turned 
so that their anterior aspect comes into view. In doing this care is to 
be taken that the attachments are not twisted on their axes. The fol- 
lowing examination from the anterior surface is then made : 

(1) Thymus gland (examination and removal). (2) Thyroid gland (dissection 
and removal). (3) Opening of the superior vena cava and its branches of origin. 

(4) Study of the termination of the thoracic duct and the great lymphatic vein. 

(5) Pericardium (inspection and opening of). (6) Examination of the cardiac 
plexus. (7) Dissection of arch of the aorta and the thoracic aorta down to the sev- 
enth costal artery. (8) Pulmonary artery and its extrapulmonary branches (separa- 
tion and opening of). (9) Pulmonary veins, extrapulmonary portion (separation 
and opening of). (10) Hilum of the lung (examination). (11) Examination of the 
exterior of the heart. (12) Removal of the heart. (13) Removal of the lungs. (14) 
Diaphragm (examination). (15) Liver and extrahepatic biliary ducts (examination 
and removal). (16) External examination and separation of spleen, stomach, pan- 
creas, and duodenum. (17) Removal of oesophagus, stomach, pancreas, and duo- 
denum. (18) Exterior examination, dissection, and removal of intestinal canal, 
with the exception of the rectum: (a) small intestine, (b) caecum, (c) vermiform 
appendix, (d) colon, (e) rectum, (/) anus. (19) Examination of the peritoneum: 
(a) mesentery, (b) omentum, and (c) parietal peritoneum ; (d) pelvic cavity. (20) 
Urinary apparatus (separation and examination of) : (a) kidneys; (b) ureters; (c) 
bladder; (d) urethra. (21) Genital organs: (a) prostate, vesiculse seminales, vasa 
deferentia, and testicles; (b) oviducts, broad ligaments, ovaries, vulva, vagina, and 
uterus. 



x This mode of procedure presents greater advantages in a child than in an 
adult, as in finding the ductus Botalli and in tracing a diphtheritic exudate in 
the air-passages. 



2 



i8 



POST-MORTEM EXAMINATIONS 





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POST-MORTEM RECORDS IO , 

In post-mortem books prepared for hospital records it is advan- 
tageous to have some data printed at the top of each page if the 
book be a large one or at the top of the left-hand page alone if the 
book be less than ten by fifteen inches, so as to afford ample room for 
notes. In my service at the Pennsylvania Hospital I used the form 
given on the opposite page. 

The routine order of examination to be employed in the making of 
the autopsy, as given on page 14, may then follow, or a card showing 
this order may be displayed in such a manner as readily to be seen by 
the one making the autopsy and the person to whom the notes are 
being dictated. Figures corresponding to the numbers of the divisions 
in the list may then be placed just before the notes describing the 
lesions to be sought for in the parts under examination. 

Many writers advise the use of more or less elaborate printed de- 
scriptions of the various anatomic regions and organs, with blank 
spaces to be filled in at the time of making the autopsy. Printed books 
and forms for this purpose are to be found on the market, 1 especially 
in England. This method of keeping notes has not in my hands 
yielded as satisfactory results as the one just described. I give, how- 
ever, the following example of a post-mortem record, which was pre- 
pared in 1890 by Dr. Formad and myself and was in use for a number 
of years at the Philadelphia Hospital. The opposite (right-hand) page 
contained no printed matter, and could be used for more extensive 
descriptions or for the dictated record of the entire autopsy. 

1 The best one in America is Warthin's Blank-Book for Autopsy-Protocols, 
published by George Wahr, Ann Arbor, Mich. It contains room for the recording 
of ten autopsies. 



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, 20 POST-MORTEM EXAMINATIONS 






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22 POST-MORTEM EXAMINATIONS 

Protocols of Autopsies in the United States Army, Navy, 
and Public Health and Marine-Hospital Service. — In investi- 
gating the methods which obtain in the three public services in regard 
to the performance of autopsies one is forcibly impressed with the 
fact that there is no uniform method of making post-mortem examina- 
tions and of recording the pathologic conditions observed. 1 With 
authority thoroughly to investigate the cause of death in practically 
all cases which die in service, it will be readily seen what a vast wealth 
of material is rendered practically valueless for comparative study 
through their lack of coordination. It must be thoroughly understood, 
however, that the author appreciates the fact that the amount of work 
in these services is exceedingly large, and that he does not desire to 
suggest anything which will still further complicate matters. If some 
regular form, as that suggested on page 14, could be officially 
adopted the advantages accruing to the medical profession at large 
become apparent, especially when one realizes the large amount of 
tropical work the public services are performing at the present time. 
In the Army an endeavor is made on the part of medical officers to con- 
form to the outline given in the first edition of this book. This is not 
compulsory, however. The officer in charge of the autopsy may follow 
any technic which he personally prefers, and the same is true in regard 
to the records maintained and the further bacteriologic and microscopic 
investigations of any given case, these all depending upon the indi- 
vidual interest in the pathologic side of medicine. Every Army post 
hospital is equipped for the performance of autopsies with the list given 
on page 43. 

In the Navy practically the same conditions obtain as in the Army. 
Autopsies are performed when practicable, particularly in those cases 
in which, ante mortem, interesting conditions are noted. No definite 
instructions are given the officer in charge. It may be well to note 
another point in this connection, and that is that, in practically all 

1 One only has to refer to the postmortems performed by' Harrison Allen 
{Proc. Path. Soc. of Phila., 1864, vol. ii, p. 160) at the Lincoln General Hospital in 
Washington to see what good work has been accomplished in many instances. That 
the question of a uniform method of making autopsies has been under con- 
sideration, is seen by the scheme for performing an autopsy prepared by Bow- 
ditch (United States War Department, Surgeon-General's Office, Form of 
Record of Autopsy, being an extract from a report of Dr. Bowditch to the 
Mass. Med.-Leg. Soc, Feb. 1, 1882, published for medical officers of the Army. 
Washington, 1882). 



POST-MORTEM RECORDS 23 

severe cases of disease or injury, the patients are transferred when- 
ever practicable to a shore hospital, and thus the actual necessity for the 
performance of an autopsy on board a man-of-war is rare. 

The Marine-Hospital Service has, on the other hand, a definite 
routine, as is shown by the following abstracts from the " Regulations 
for the Government of the Public Health and Marine-Hospital Ser- 
vice" of the United States; approved August 12, 1903, par. 696: " A 
separate report will be made of each necropsy to be typewritten on legal 
cap paper, and on one side only of the sheet, and otherwise prepared 
with care for publication. Each report shall include the diagnosis, 
initials, age, nationality, date of admission (with name of station), 
and date of death of the seaman. Each report will be accompanied by 
a complete clinical history and forwarded to the Bureau as soon as 
completed." Further instructions relative to necropsies to be found 
in the Appendix are : " Examinations shall be made in accordance with 
methods prescribed in Virchow's Post-Mortem Examinations and shall 
include the following: (A) The calvarium is to be removed, and the 
condition of the skullcap, the brain-case, the sinuses and vessels, and 
the brain and its membranes noted. (B) In the thorax the exam- 
ination will include the anterior mediastinum, the heart and pericar- 
dium, the lungs and pleura, the great vessels and nerve trunks, and the 
diaphragm. (C) In the abdomen the examination will include the 
omentum, spleen, kidneys and suprarenal capsules, urinary bladder, 
organs of generation (prostate, seminal vesicles, testicles, penis, and 
urethra), rectum, duodenum, stomach, gall-ducts, liver, pancreas, solar 
plexus, mesentery, small intestines, large intestines, and the great 
vessels. (D) In cases involving disease of or injury to the spinal cord 
the examination will include the cord and its membranes. (E) Micro- 
scopic examinations shall be made of pathologic processes and sus- 
pected organs. When it is not practicable to make these examinations 
at the station, specimens should be sent to the Bureau. For this pur- 
pose nervous tissue should be placed in Muller's fluid, lung tissue in a 
solution of 5 per cent, formaldehyd, and other organs in alcohol, 50 
per cent. The specimens should be from one to two centimetres 
square, and carefully labeled." 

Note Taking. — Relying upon one's memory for records is a 
treacherous practice, and appearances which seem to be of no impor- 
tance while the organ is before you are often of value to others who 
for various reasons may be called upon to read the protocol of the 



24 



POST-MORTEM EXAMINATIONS 



autopsy, but who have not had the opportunity of examining the parts 
in which they are interested. It is important, especially in medicolegal 
cases, to write " examined" or " normal" * after the number referring 
to the part under study, where no lesion exists, as this shows that an 
actual examination of .this portion of the body has been made. 

The notes should always be dictated in a distinct tone of voice 
and in easily understood language while the autopsy is in progress, and 
should consist exclusively of descriptions of the conditions then and 
there observed. Numbers and doubtful words should be at once re- 
peated by the scribe, as an additional safeguard against error. Like 
the anaesthetist at an operation, the amanuensis should pay strict at- 
tention to the work assigned him. Names of diseases should be 
omitted in the notes themselves, but are to be inserted under the head- 
ing of " Pathologic Diagnosis" at the head of the report. The record 
of morbid changes present ought to be full, clear, and exact, so that 
from it alone the pathologic lesions can be inferred by another pa- 
thologist as well as by the one who performed the necropsy. If the 
post-mortem record is rewritten, any descriptions given during the 
superficial examination may be combined with the detailed account of 
the parts removed from the cavity examined, thus permitting of the 
omission of any possible repetitions. One well-worded description 
of an autopsy dictated to a reliable amanuensis during the progress of 
the work is of much more value than scores written from memory 
after their completion. Drawings, photographs, skiagraphs, krom- 
skopic pictures, casts, microscopic slides, properly mounted museum 
specimens, and cultures of micro-organisms make valuable additions 
to a well-written account of a postmortem. 

The liability to mistake, of which every day furnishes examples, is 
nowhere more forcibly exemplified than in the performance of post- 
mortems and the description of the appearances of the parts examined. 
What serious errors may result from poor writing or through mis- 
understanding, as in conversations over the telephone, is shown by 

Objection to the use of the word "normal" may properly be raised, for what 
one person may consider normal another would class as abnormal, while its use by 
an inexperienced person might lead to the omission of certain data which might be 
of importance in the future. It is, therefore, well to describe the part in detail. This 
will not only impress upon the obducent the normal appearances, but also lead him 
to make a more critical examination than he otherwise would be likely to do. The 
comparison of one organ with its fellow or of one part of the organ with another is 
often of value in this connection. 



POST-MORTEM RECORDS 



25 



the following illustrations. A pathologist communicated by telephone 
to the secretary of a surgeon the diagnosis of adenocarcinoma. The 
report received by the surgeon was to the effect that the patient " had 
no" carcinoma. 1 Often the word " atypical" is understood in the sense 
of " a typical." There is also an amusing side to this subject. In 
abstracting an article by Banti for the International Medical Magazine 
in 1895, tne author wrote of the bacillus there described as being 4 p. 
long by 1 fi broad. The style of the office where the magazine was 
printed was to spell out numbers, and, as the compositor mistook the 
writing of the Greek letter n for ft., it appeared in the galley proof that 
" The bacilli are four feet long by one foot broad" ! 

Post-mortem records may be kept in a book specially prepared for 
that purpose, or on sheets to be filed away with the clinical history of 
the case under consideration. To every autopsy performed by myself 
I give a specific number, and lately have preserved my records on sheets 
kept in a flat-opening note cover-book, until they are ready to be filed 
away and indexed in properly made manila covers. The interchange- 
able sheets in the note-book measure seven by eight and one-half 
inches. By means of an ingenious clasp opening in the centre, one 
end being fixed and the other movable, the leaves are held in place by 
passing the clasp through two small circular openings on the left-hand 
side of the page. When the clasps are closed, the leaves can be turned 
like a book; when open, one or more sheets may readily be removed 
or others inserted. This method I find superior to the practice of 
keeping the records in special books or on the large index cards which 
are used by many physicians in preserving their private case records. 2 

The following characteristics of each organ are to be noted, par- 
ticular attention being given to those structures which are most vitally 
connected with the functional activity of the part. 

1. Situation and relation to other parts. 

2. Size and weight. 

3. Shape, contour, borders, and coverings (capsule, serosa, mucosa, etc.). 

4. Color. 

5. Consistency. 

6. Anomalies and malformations (congenital and acquired). 

7. Fractures, dislocations, and lacerations. 

8. Cut surfaces and liquid exuded. 



1 Amer. Med., December 5, 1903. 

2 International Clinics, 1902, vol. iv, Eleventh series. 



26 POST-MORTEM EXAMINATIONS 

9. Cavities, special attention being paid to their contents and to the linings 
of their walls. 

10. Odor. 

11. New growths. 

12. Other pathologic conditions, taking into account the condition of the 
vessels to and from as well as in the part under consideration. 

i. Situation and Relation to other Parts. — This takes into account 
any departure from the normal position or attachments of the organ. 
There are a number of regional landmarks frequently used; thus, 
in the case of the diaphragm we speak of its height in relation to the 
ribs or the intercostal spaces; of the stomach, as extending so many 
inches above or below the umbilicus; of the heart, in its relation to 
the nipples and the xiphoid cartilage ; and of the cord, as to the verte- 
bra?. While it may usually be easy to distinguish from which side an 
organ has been taken when there are no marked changes in its shape, 
the author has found that much time is saved and confusion avoided 
by marking each of the double organs as it is removed from the body, 
— one nick for the left- and two nicks for the right-sided organs. 

Plate I, which will be found upon the inside of the front cover, is 
based upon Cunningham's Anatomy, and will be helpful in the prep- 
aration of outline charts of the body for recording the situation and 
extent of lesions discovered at postmortems. The drawing shows 
the normal relations of all the important thoracic and abdominal 
viscera. Those who are unable to draw can place a sheet of thin paper 
over the figure and prepare an outline, which, after being filled in 
according to the exigencies of the case, may be pasted in the notes 
for future reference. One may purchase English-made gummed outline 
charts in sheets of the brain and other parts of the body, upon which 
may be sketched in black ink the lesions which it is desired to record. 
Such drawings without further change may then be sent at once to the 
engraver for reproduction in order to illustrate matter intended for 
publication. 

2. Size and Weight. — For tables of weights and measures of the 
body, see Chapter XXIV. Whenever possible, it is advisable to give 
dimensions in centimetres and weight in grammes; if, however, 
measures and weights are to be used when giving testimony in a court 
of justice, it is well to convert them into inches and pounds, ounces, 
and grains avoirdupois, before going on the witness stand. The size of 
an organ naturally depends much on the size and weight of the body. 



1 2 3 4 5 MILLIMETRES 8 



9 10 1 2 3 




POST-MORTEM RECORDS 2 ^ 

It should be remembered that a large organ is not necessarily a heavy 
one. Atrophy and hypertrophy may be present in the same part, as seen 
in cases of hypertrophic cirrhosis of the liver in which acute yellow 
atrophy has supervened. As nearly as possible similar conditions should 
be employed in the preparation of the organs for weighing. Thus, 
about one inch of the large blood-vessels is usually left attached to the 
heart previous to weighing and the renal pelvis of the kidney and a 
portion of the ureter is weighed with the kidney. 

For determining bulk various means are employed besides actual 
measurement. A number of familiar objects at once suggest them- 
selves, which may be used for comparison in describing the size of a 
lesion or part. And the importance of thoroughly familiarizing one's 
self with the dimensions of objects seen daily is illustrated by the 
fact that most persons have only vague and more or less erroneous 
notions concerning the dimensions of many common things, such 
as the head of a horse (usually underestimated) or the height 
from the ground of a stationary wash-stand (generally overesti- 
mated). A lesion may appear larger or smaller by being elevated or 
depressed and of a color like or unlike that of the surrounding parts. 
Virchow had, in the old Charite dead-house before its destruction 
by fire on January 16, 1901, a cabinet containing specimens of various 
familiar objects, such as beans, peas, lentils, barley, etc., with which 
pathologic lesions could be compared. (Plate II.) Later on, recogniz- 
ing the relation of specific gravity to size and weight, he estimated the 
size by noting the quantity of water displaced by the organ when placed 
in a large vessel of known capacity. 

3. Shape, Contour, Borders, and Coverings {Capsule, Serosa, 
etc.). — All deviations from the normal in these particulars should be 
noted, as valuable information may be gained thereby. Thus, the shape 
of the uterus may point to a probable previous pregnancy. The sym- 
metry of the organs should be looked for, and comparisons made of 
one part with another. The form of an organ is often markedly 
changed by its removal from the body. Freezing the bodies and 
injecting them with formalin are the best methods used of deter- 
mining the real shape of the parts. That marked changes occur in 
life under normal conditions is seen on comparing the lung during 
an operation upon the chest in a condition of expiration with that of 
inspiration. An organ may retain its normal size and to a large extent 
its shape, and yet the parenchymatous tissue be markedly decreased, 



2 8 POST-MORTEM EXAMINATIONS 

as when the pelvis of a kidney is filled with fat. It is often advisable 
to use the name of some well-known object in describing the con- 
figuration of a part, — e.g., cauliflower growth, mushroom-shaped, 
hobnail, hour-glass contracture, beaver-tailed, horseshoe, sago, bread- 
and-butter, pig-backed, etc. As to the external appearance of a solid 
organ, its surface may be smooth, granular, nodular, shrivelled, or 
puckered. Here also we describe the capsules of organs, the serous 
coverings of the various parts, — as of the liver, brain, etc., — the mucous 
membrane, — as of the stomach, vermiform appendix, etc., — being con- 
sidered after the opening of the part. The borders of organs that 
have undergone infiltration are usually rounded and filled out; in 
degenerations they are generally flatter, thinner, and sharper than 
normal. Thus, in fatty infiltration the edges of the liver are rounded, 
while in cirrhosis its margins, often so largely composed of connective 
tissue as to contain practically no liver-cells, are sharply defined. The 
general contour of the blood-vessels may be markedly changed, as in 
aneurisms. 

4. Color. — It is most difficult to describe colors or to reproduce 
them satisfactorily. In the reproduction of color " three-color" print- 
ing does not give, as yet, such" good results as lithography. The best 
color-values are obtained by the kromskop, 1 which has a wide field 
of usefulness not sufficiently recognized. Color differs when viewed 
from a long or short distance. For purposes of comparison colored 
chalks or oculists' colored worsteds can be used. The primary colors 
yellow and red are chiefly met with, as also various shades of brown, 
which is a mixture of these two with some black added. Other colors 
found are slate, shades of gray and of yellow, blue, and green. The 
numerous shades and gradations of red are the most common tints 
found in the body. There is no such thing as pure white, even the con- 
junctivae being a pearl-grayish pink. In pathology the word " pale" 
means relative deficiency of color. The color of adjacent parts may 
bring out or hide pathologic lesions. Color may point to a post-mortem 
change, as the red color of the aorta seen in imbibition, or to a lesion, 
as the appearance of blood-vessels in the valves of the heart. One may 
not be able to distinguish an artery from a vein at the postmortem by 
color alone. The color of an organ or part is to be noted as soon as 
possible after exposure, as air, light, and water tend to alter it con- 

1 Cattell, International Clinics, 1900, vol. ii, Tenth series. 



POST-MORTEM RECORDS 2 g 

siderably, though naturally more or less change has already been 
brought about by death. Thus, the pericardium, which during life 
is transparent, is at autopsy only translucent. An organ should not 
be washed before its color is described, as water removes part of the 
coloring matter present, acts on the proteids, and modifies the original 
consistence of the organ; these changes may readily be demonstrated 
by placing the thymus gland, with the surrounding areolar tissue, in 
running water for five minutes. The natural juices of the body may 
cause alterations in color; thus, the gastric juice turns blood to a 
brownish tinge. Air oxidizes the blood, so that a bluish stain may 
in a short time change to bright red. In the case of a congested lung 
it is well to note its appearance both before and after the blood has 
become oxidized. Certain abdominal organs are frequently discolored 
by a greenish slate tint supposed by some to be due to the deposition of 
the iron from the haemoglobin by the hydrogen sulphid arising from 
decomposition. It would add materially to our knowledge if sur- 
geons were to inform pathologists under what circumstances this con- 
dition is seen during life. In a case of ammonium hydrate poisoning 
observed by the author, although the body was well preserved, the 
characteristic discoloration had penetrated the substance of the liver to 
a depth of three-quarters of an inch. In this instance a rod dipped in 
hydrochloric acid and held in the cranial cavity after the removal of the 
brain gave off fumes of ammonium chlorid. Poisons often change the 
color of the blood markedly, and degenerations and infiltrations alter 
the color of the various parts affected. For a further description of the 
blood the reader is referred to page 126. 

5. Consistency. — This is learned only by experience, and is deter- 
mined by pinching the organ between the thumb and the index-finger 
and by noticing its behavior when held in the hand. According to 
Oestreich, 1 the best method of determining the consistency of an 
organ is, with closed eyes, gently to raise the part from beneath with 
a lateral pressure by means of the moistened fingers exclusive of the 
thumb. Hollow organs should be tested both before and after opening. 
It should be remembered that consistency is affected by the season of 
the year, by the temperature of the cadaver and of its surroundings, by 
the length of the interval between dissolution and the autopsy, by the 
manner of death, by the means used for the preservation of the body, 

1 Allgemeine pathologisch-anatomische Diagnostik, 1905, p. 13. 



30 POST-MORTEM EXAMINATIONS 

and by various other influences. The name applied to the pathologic con- 
dition often shows the consistency, as malaria (soft), in osteomala- 
cia, and the hepatization of croupous pneumonia (hard). Elasticity is 
seen, as in the aorta, which in health may be stretched several centi- 
metres. Parts when once pressed may not return to their previous 
condition, as in fatty liver or oedema of the lungs. Organs are hard- 
ened by an increase in connective tissue, as in cirrhosis of the liver ; by 
deposits of lime, as in calcareous infiltration of the coronary arteries, 
etc. Consistency differs before and after death, and is much modified 
by rigor mortis (increased) and by decomposition (diminished). 

6. Anomalies and Malformations (Congenital and Acquired). — 
Each part or organ is subject to its own peculiar anomalies and 
malformations, which depend on the embryonal stage at which 
they occur. An entire chapter might readily be written upon the 
various altered conditions, congenital and acquired, revealed by au- 
topsies. Thus, the author has seen perforation of a typhoid ulcer in 
a Meckel's diverticulum ; free calcified bodies in the abdominal cavity ; 
peculiar curvatures of the iliac arteries; the left kidney shaped like 
the spleen ; the tip of the vermiform appendix resting near the pyloric 
end of the stomach; an artificial anus made by the rupture of a 
typhoid ulcer; the vermiform appendix in a left femoral hernia and 
the sigmoid flexure in a right inguinal hernia; a fish-bone in the 
omentum, etc. 

7. Fractures, Dislocations, and Lacerations. — Every degree of 
injury may be represented. It should be remembered that from the 
external appearances alone it is not possible to state definitely the 
extent of the internal lesions. A heavy wagon may run over a child 
without rupturing the skin, though the internal organs may be lacer- 
ated and torn to a remarkable extent. The writer had an instructive 
case where a man struck a lamp-post with a push-cart, the handle of 
which struck his hepatic region; the external injury was not larger 
than a silver dollar, but hemorrhage from laceration of the liver 
finally caused death. Injuries are especially apt to be overlooked in 
those parts which are covered with hair. Artificial fractures of the 
organs afford abundant opportunity for study. This is best accom- 
plished by making a small incision in the organ and then tearing it 
apart by force. Compare the difference under these conditions between 
an amyloid and a fatty liver, or a heart affected with fragmentary 
mvocarditis and the normal heart. 



POST-MORTEM RECORDS 3I 

8. Cut Surfaces and Liquid exuded. — When an organ is incised, 
describe first that which is most striking, as, for example, the presence 
of a hydatid cyst that is exposed on section of the spleen. Note the 
color of the exposed surface; whether it is smooth or granular; dry, 
as in dry gangrene, or moist, as in liquefaction necrosis ; the amount, 
character, and chemic reaction of the fluid that is spontaneously exuded 
or is obtained by scraping with a knife (the material thus obtained 
is at once examined with the microscope) ; and the condition of the 
blood-vessels, especially as to atheroma and thrombosis. Numerous 
incisions may lead to the discovery of new lesions or afford an oppor- 
tunity of studying the morbid process in its various stages. Under the 
term " liquid exuded" are included not only blood, transudates, and 
exudates that follow incision of the part, but also any fluid that may 
be contained in the cavity of a hollow organ or in a cyst present and 
the juice that appears on scraping and squeezing. CEdema of an organ 
may be detected by squeezing it. In the lungs a frothy cedematous 
material shows the absence of a pneumonic infiltration. 

9. Cavities. — In opening any cavity look for blood, mucus, pus, 
transudates, exudates, specific secretions and excretions, and stones. 
In describing cavities pay especial attention to the lining membranes, 
noting their color, lustre, smoothness or roughness, and the presence 
of any adhesions ; also the quantity, color, consistence, odor, and reac- 
tion of their contents and any sediments found therein. Normal 
cavities may be increased or diminished in size and singular or multi- 
form new cavities may be formed. The gaseous contents of cavities 
is a most interesting and unexplored field of original investigation. 

10. Odor. — It is safe to predict that more and more attention will 
be given to the significance of odor. The organ of smell is imperfectly 
developed, and varies greatly in different individuals and in the same 
individual at different times. The peculiar odor that accompanies the 
growth of certain bacteria, such as the Bacterium coli commune, is well 
known. Smallpox, measles, cancerous ulcerations, and gangrene of 
the lung have their peculiar stenches. We may also mention the 
odor of acetone in diabetes, the pus-like odor in leucocythsemia, the 
butyric-acid-like or alcoholic odor from the brains of those who have 
drunk heavily before death, the ursemic odor, the odor in cases of 
carbolic or hydrocyanic acid poisoning, etc. The following poisons 
may also be recognized by their odor: ammonia (see p. 29), amyl 
nitrite, aromatic oils, bromin, bromoform, camphor, chloral, chlorin, 



32 POST-MORTEM EXAMINATIONS 

chloroform, creosote, ether, ethereal oils, formalin, hydrochloric 
acid, indol, iodin, iodoform, methylic alcohol, nicotine, nitro- 
benzol, opium, osmic acid, paraldehyd, phosphorus, skatol, sul- 
phuretted hydrogen, sulphuric acid, tellurium salts, and turpentine. 
Fischer and Penzoldt 1 state that the one five-millionth part of a 
gramme of chlorphenol or of mercaptan may be recognized by the sense 
of smell. For another illustration, see the action of the Penicillium 
brevicaule on arsenical preparations, Chapter XXVIII. We should not, 
however, err in the other direction, for too often a case of apoplexy is 
taken to a police-station and the diagnosis is there recorded as one of 
alcoholism, simply because the odor of alcohol is found on the person 
arrested. 

ii. New Growths and Parasites. — It is important to determine at 
once the presence of tumors, cysts, worms, etc., in a part, as subsequent 
manipulations may have to be markedly altered by their discovery. 

12. Pathologic Conditions. — Every death may be attributed to one 
or more of the three following ultimate causes : I. Interference with 
respiration, called asphyxia or apncea ; II. Interference with the heart's 
action, called syncope ; and III. Interference with the nervous system, 
called coma or shock. The number of distinct diseases capable of 
producing death is limited, as will be seen by reference to the Bertillon 
classification of the causes of death given in Chapter XXX, the list 
not being nearly so large as one might expect without due considera- 
tion of this subject. There is also a distinct repetition of morbid 
processes in the different diseases and in the different parts. It is also 
well to remember that the histologic structure of an organ often at 
once gives information as to the lesions which will possibly be present 
in an affected part. In making a postmortem the diseases from which 
a person is liable to die and the lesions which may be found in any 
individual part or organ should always be carefully considered. Bear- 
ing this point in mind, considerable care has been taken in the prep- 
aration of the index in order to aid the reader in reaching a proper 
diagnosis by refreshing his memory as to the possible diseases or dis- 
turbances that may take place in the part or organ under study. By ex- 
clusion, the character of a lesion under observation may often at once 
be reduced to two or three possibilities, the final diagnosis being 
reached, in many cases, only by microscopic study. The index will 

1 Jr. Amer. Med. Assoc, April 23, 1904. 



POST-MORTEM RECORDS 33 

also be found of use as suggestive in the preparation for an examina- 
tion in pathology before a State Board or elsewhere. 

Every pathologist is familiar with cases in which it was im- 
possible to state positively the cause of death, even on the completion 
of an elaborate autopsy and subsequent thorough examinations by the 
chemist, bacteriologist, and microscopist. In such instances, as in all 
others, the accuracy of the conclusions drawn will depend upon the care 
exercised in the observation of details. Fortunately for those having to 
do with cases coming under the notice of the Coroner, sudden death is 
nearly always attended by well-marked pathologic lesions. When nc 
such cause of death is found, chemic or early microbic poisoning should 
be suspected. Any epidemic disease, such as smallpox, which is now 
(1906) so widely distributed throughout America, should always be 
thought of during the time of its prevalence, as death therefrom may 
occur before the characteristic rash or symptoms have appeared. 

A lesion found in one portion of the body may indicate the exist- 
ence of pathologic conditions in another perhaps remote part. For 
example, multiple melanotic sarcomata of the liver are frequently 
secondary to a primary growth in the eye; embolism in the brain 
often arises from malignant endocarditis; hasmatomata of the ears will 
suggest chronic meningoencephalitis, with thickening of the cranial 
meninges; a stricture of the urethra may cause hypertrophy of the 
bladder; and the presence of miliary tuberculosis should lead to an 
examination of the pulmonary arteries for tuberculous thrombi arising 
from caseous tuberculous glands. Again, particles of coal-dust em- 
bedded in the hands demand a careful inspection of the lungs for 
anthracosis, while bronzing of the skin will suggest scrutiny of the 
adrenals and of the sympathetic ganglia (Addison's disease). 

Bond's interesting experiments * have shown that the ascending 
currents to be found in mucous canals and the ducts of glands are 
prolific sources of infection not hitherto sufficiently recognized. Steril- 
ized pigments were placed in various apertures of the body before 
operation and the neighboring organs were examined after removal in 
order to discover if they had been reached by these substances. Thus, 
when the colored matter was placed in the vagina, the particles would 
pass into the oviducts and thence to the peritoneum covering the broad 
ligaments. 

1 Med. Notes and Queries, September-October, 1905, p. 130. 

3 



1 



CHAPTER III 

POST-MORTEM INSTRUMENTS AND HOW TO USE THEM 

Various combinations of post-mortem instruments are found in the 
sets catalogued by dealers, but these, except for the systematic work 
possible only in hospitals and morgues, are more luxurious than neces- 
sary. The former wooden box with its plush lining is an abomination, 
owing to the impossibility of keeping it in a cleanly condition. The 
metal box is satisfactory, and one should be employed which can 
occasionally be sterilized by heat in its entirety. The ends of the box 
should be rounded so as to prevent any sharp edges from injuring the 
hands of the operator. If a box be used, all instruments should be 
thoroughly disinfected and returned to their proper places after each 
postmortem. It is annoying to take such a box to the place where 
the postmortem is to be held and then to discover the very instrument 
wanted to be missing. The instruments that are really indispensable 
for the proper performance of an autopsy are very few in number, 
as a complete examination may be performed in case of an emergency 
with a penknife and an ordinary wood-saw. Of course, in this field, 
as in surgery, ample opportunity has been offered for the exercise of 
mechanical ingenuity, and many instruments have been devised for 
facilitating post-mortem work that save much time and render greater 
neatness and exactitude possible. 

The following list contains the instruments, apparatus, and chemi- 
cals most commonly used in the performance of an autopsy. 

Knives. — Section- or Cartilage-Knives. — These should be made 
very strong, with a broad back; blunt, rounded ends; and a bulge or 
belly at the outer third (Fig. 14), becoming narrower at the at- 
tachment of the blade to the handle. For general purposes the 
length of the entire knife should be from seven to seven and a half 
inches (about eighteen centimetres), the handle measuring about four 
inches. The Germans use knives even as long as eleven inches (twenty- 
eight centimetres, with a blade of sixteen centimetres). The rounded 
expansion for the index-finger found on the back of some section- 
knives is unnecessary (Fig. 15). The sharp-pointed knife should in 
all instances be rejected (Fig. 16). When the knives are sent to be 
34 



Fig. 14. — Section- or cartilage-knife, with rounded end. (One-half natural size. 




Fig. 15. — Cartilage-knife with projection on back upon which the index-finger rests when making incisions. 

(Two-thirds natural size.) 




Fig. 16.— Post-mortem knife with faulty point and without proper belly. (Two-thirds natural size.) 



" , . 1 n J 1 1 ■ , 1 1 1 , 1 j t u 1 1 1 ! 1 1 1 i i : ■ n i 1 h 1 1 1 ; J i 1 1 i J ; ; 1 1 . ; , 1 : ! 1 ■ ; ; , J i 1 ' , : : ' U ii ! 1 ! i j : ! ! 1 ^ ! > j 1 1 1 i 1 i ; 1 m 1 1 1 n 1 ; 1 u n l n 1 1 ! . 1 ii u 1 11 1 1 j i j 1 1 1 , | ! 1 1 11 

I 2. 3 4- 5 ff 7 * 8 S ID II 12 13 14 15 



Fig. 17. — Coplin's brain-knife marked in centimetres on one side and in inches on the other. (Reduced.) 




Fig. 18. — Bread-knife, useful in incising large organs, as the brain, the liver, etc. It comes in two 
forms, — with both sides meeting at the cutting edge like an ordinary knife, or with one side perpendicu- 
lar and the other slanting for about three-eighths of an inch above the sharp edge, as shown near the 
handle in the illustration. (One-third natural size.) 




Fig. 19.— Valentine's knife. (One-half natural size.) 



Fig. 20— Pick's myelotome. This little instrument is useful for severing the spinal cord in the removal 
of the brain. (One-half natural size.) 




I I 



: '^ : -' :: 




^ 



I J 



V 






5. 






• 



Fig. 21. — i, desirable form of forceps with spring; 2, saw with rounded end ; 3 and 4, proper shapes of needles; 5, 
small saw with rounded end; 6, spring forceps; 7, box-jointed tenaculum forceps; 8, solid-headed hammer; 9, steel 
tape measure; 10, combined hone and strop (a strip of aluminium may be used for this purpose); 11, scalpel with 
rounded hard-wood handle. (Reduced about one-half.) 




Fig. 22.— A very desirable saw for post-mortem work ; it is solidly constructed, and the teeth on the 
curved end are useful for sawing- out the angles in the removal of the skullcap by the angular method. 
(Slightly less than one-half natural size.) 




Fig. 23.— Butcher's saw, with teeth facing forward, very useful for quick work in opening the calva- 
rium. (One-quarter natural size.) 




Fig. 24. — Hey's (Pare's) saw. (Two-thirds natural size.' 




Fig. 25. — Metacarpal saw. (Slightly less than two-thirds natural size.) 




Fig. 26. — Luer's double rhachiotome. This instrument is worked with the right hand and steadied 
with the left by means of the handle attached to the fixed blade, the other blade being movable by 
clamps, so that the distance between the parallel blades may be varied at the will of the operator. The 
sawing is done towards the hip, except for the upper cervical bones, where it can best be done towards 
the occipital bone. This instrument should not be used in marked deformities of the vertebral column. 



POST-MORTEM INSTRUMENTS AND THEIR USE 35 

sharpened, the instrument-maker should be cautioned not to grind them 
to a point. Scalpels, such as are used in dissecting. Those made of a 
single piece of metal — i.e., without wooden, bone, or ivory handles — 
are to be preferred. The brain-knife (Fig. 101) should have a thin 
blade about ten inches (twenty-five centimetres) long, one and a half 
inches (four centimetres) broad, and be blunt at the end like a table- 
knife. This instrument may also be used for incising the large organs 
and in opening the cavities of the heart. The brain-knife is sometimes 
sharpened on both edges or it may be marked in the form of a rule 
and thus serve a double purpose (Fig. 17). An amputation-knife 
may be employed in place of a brain-knife, or in removing the 
brain through a trephine opening made in the skull. A Waring bread- 
knife (Fig. 18), which also does good work, may be used for incis- 
ing the larger organs. A Valentine knife (Fig. 19), which has two 
parallel blades adjustable by screws to keep them the desired distance 
apart in order to cut at will thick or thin sections, is now rarely seen, 
but was much employed before the freezing microtome came into com- 
mon use. Pick's myelotome (Fig. 20) is an instrument with a short 
blade bent nearly at right angles to the shaft, for cutting the spinal 
cord rectangularly to its axis instead of in an oblique direction. A 
curved, probed-pointed bistoury is also used in cutting the dura mater, 
spinal cord, etc. A razor was formerly included in all lists of post- 
mortem instruments, but is now discarded. 

Saws. — The saw should possess a strong blade solidly attached 
to the handle, as the two-piece jointed ones, kept in place by a screw, 
are very liable to become loosened. (Figs. 21, 2 and 5, and 22.) 
A butcher's meat-saw, which is arranged like a scroll-saw (Fig. 23) 
with its teeth pointing towards the front, its cutting surface measur- 
ing from ten to fourteen inches (twenty-five to thirty centimetres) 
for an adult and six inches (fifteen centimetres) for a babe, or a 
large cross-cut carpenter's saw, does the quickest work in removing 
the calvarium. Hey's saw (Fig. 24) is useful in sawing the angles 
when opening the skull. A metacarpal saw (Fig. 25) is often of 
service, especially in examining the femur of a babe for the detection 
of syphilitic osteochondritis. A wire saw is seen in use in Fig. 163. 
Schalle (Virchow's Archiv, vol. lxxi, p. 206) gives a good account of 
how to use it. Van Walsem has prepared a special saw, which he 
calls cranio prion, for opening the skull without injury to the dura. 
Luer's double rhachiotome (Fig. 26), employed for opening the spinal 






36 



POST-MORTEM EXAMINATIONS 



column, consists of two parallel saws with curved blades, the distance 
between which can be regulated by screws, and a very firm handle with 




Fig. 27. — Masland's electric saw and stand. 1, electric wiring; 2, electric motor; 3, curved portion 
of support; 4, means for elevating motor; 5, saw in use. 



a strong central support. Various forms of dental and trephining 
engines, usually driven by electricity, have recently been introduced and 
are useful in saving time and labor. Among such engines may be men- 




Fig. 33, 



-Proper form of costotome ; the handles do not meet by one-quarter of an inch and the ends 
are not pointed, but rounded. (One-half natural size.) 




Fig. 34. — Improper form of costotome, with pointed blades and a catch, the handles meeting when the 
instrument is closed. (One-half natural size.) 




Fig. 35.— Steel hammer with proper handle. (One-half natural size.) 




Fig. 37. — Curved chisel, 
used for the same purposes 
as Fig. 36. (One-half natural 
size.) 





%■ ' • ■ V.Sa\V> 














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' '■'*■:■ J -'A 




fc* v 


:^'®-"'y-P 




1 


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Ifctf* 


l " !. \ '•■•'?■; 


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H&9 


':.-. ■:■■& •'■:■■ 




?- ( 






$• 


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Stll^-- ; fl| 


w®$ 


> . ■" }#> 




r.-r^VJj 





Fig. 36. — Solid steel side 
chisel for breaking through any 
unsawed portions of bone in re- 
moving the calvarium. The 
pointed end is used as a pry and 
retractor for pulling out the 
sawed-off portion of the skull. 
(One-half natural size.) 



Fig. 38. — Brunetti's left curved 
spinal chisel, of use in opening the 
vertebrae. (One-half natural size.) 




Fig. 39.— Dura tongs. 




Fig. 40. — Forceps. 



Fig. 41.— Straight grooved director. (One-half natural size.) 




Fig. 42.— Satterthwaite's cal 



varium clamp, closed and in 




Fig. 43.— Iron clamp to be applied to the skull before the removal of the brain ; especially 
used in dissecting-rooms. 





Fig. 44. — Bigelow clamp for holding the 
head in the removal of the brain. 



Fig. 45.— Folding iron head-rest. 



POST-MORTEM INSTRUMENTS AND THEIR USE 



37 



tioned those of Cryer, 1 de Vilbiss, Wright, Sykes (English), Masland 
(Fig. 27), 2 etc. These instruments are high priced ($100 to $300), 
on account of the infrequent demand for them. Hand-driven instru- 
ments may be purchased for twenty-five dollars and upward. 

Scissors. — One pair of scissors should be large and strong, with 
long handles and short, stout blades (Fig. 28) ; the other pair should 
have rounded ends with handles at an angle of forty-five degrees 
(Fig. 29). A pair with separable blades is frequently useful (Fig. 
30). The enterotome is a scissors with one short and one long blade 
(Fig. 31), the latter being blunt and curved on itself at the end. 
Be sure that there is no sharp-pointed end, as this is the form usually 
supplied (Fig. 32). The costotome (Fig. 33) is an expensive instru- 
ment, with short, thick blades, the under one being curved and 
having a strong spring between the handles. Dangerous blood-blisters 
are sometimes produced by pinching the operator's skin with the 
ends of the handles, which usually meet and fasten with a catch 
(Fig. -34). The ends should not meet and there is no necessity for 
the catch. Bone-forceps, large and strong and with rough handles, 
are desirable. One blade is blunt, so that it can be shoved against 
soft tissues without injuring them, as in cutting the ribs. 

Hammers. — The most useful hammer is made of solid steel (Figs. 
21, 8, and 35). One end of the head or striking portion is cuneiform, 
and there may be a hook on the end of the handle which is of service in 
springing off the calvarium. Lead filling in a hammer muffles the sound 
of its impact and prevents rebounding. A wooden or rawhide mallet 
is preferred by some pathologists for a similar reason. 

Chisels. — There are chisels of various patterns devised for open- 
ing different regions. The straight chisel is the most serviceable, as it 
can be used in any region. The T-shaped chisel is also generally useful ; 
it has one arm placed perpendicular to the other, and the arm which 
serves as a handle has one sharp and one blunt end so that it can be 
hammered upon. The chief use of the T-shaped chisel is in springing 
off the calvarium and in elevating the periosteum from it. Guarded, 
hatchet-shaped chisels (Figs. 36 and 37) and Brunetti's spinal 
chisels (Fig. 38) are useful in opening the spinal canal, and a chisel 
with a guard about half an inch, or 1.25 centimetres, from the edge 

1 Medical News, January 30, 1897. 

2 Proc. Phila. Count. Med. Soc., February 28, 1905. 



38 POST-MORTEM EXAMINATIONS 

will not injure the brain while springing off the calvarium from the 
dura mater. The raspatory of Chiari has a broad, spoon-shaped end, 
four centimetres wide, with which the periosteum from a large surface 
can easily be removed; the other end is of the shape of a lance, one 
inch (2.5 centimetres) long, and is used for deep separation. 
Chavigny * has devised a special lever of ingenious construction for 
the purpose of removing the spinous processes and laminse of the 
vertebral column in taking out the spinal cord. 

Forceps. — Dissecting forceps are indispensable when it is neces- 
sary to trace small structures; pointed, straight and curved forceps 
are the forms in use. (Fig. 21, 1 and 6.) Lion-forceps of special type 
may be used when removing the bodies of the vertebras. Dura-tongs 
(Fig. 39), for pulling the dura mater away from the calvarium when 
it is adherent, may prevent the fingers from being injured by the bone. 
Various forms of tongs and forceps are recommended for those who 
use gloves. (Simmonds.) Another form of strong forceps is seen in 
Fig. 40. For bone-forceps and costotome, see under Scissors. 

Grooved (Fig. 41) and curved directors are frequently of use. 

Chain hooks and a tenaculum may be employed, but they are 
dangerous instruments. Hooked retractors are more desirable than 
a tenaculum or chain hooks. 

Various Instruments. — A metal catheter and several flexible 
catheters, all of size number 8, may be needed for withdrawing urine. 
A blozv-pipe with a stop or valve, a trocar and cannula, probes, some 
of which have eyes, and some form of injecting syringe are also 
useful. A vise is serviceable in firmly holding bone preparations in 
course of dissection, and in fixing a saw that is being sharpened. A 
skull clamp is considered by some to be of use in removing the calva- 
rium (Figs. 42, 43, and 44). Iron tripods and other special devices 
for holding the head are shown in Figs. 45 and 46. 

Weights and measures of various kinds are frequently found to be 
indispensable. These should include scales, a steel tape measure (Fig. 
21, 9), graduated calipers, graduated glass cones, glass balls, and grad- 
uated measuring vessels of glass. The scales should have a capacity of 
twenty pounds, or ten kilogrammes, and be supplied with weights from 
a gramme upward. They are needed in weighing organs. The steel 
tape measure and the two-feet rule are marked both in centimetres 

1 Presse med., July 20, 1904, p. 460. 




Fig. 46. — Cornell folding clamp for the secure holding of the head in the removal of the calvarium. 
(See article by B. B. Stroud in the Proc. Assoc. Amer. Anat., May, 1900, p. 10, and the Med. News, 
December 9, 1905. In the later communication, an iron form of head-rest is described. Specifications 
for the making will be sent upon application to the author.) 




Fig. 49. — Metal pocket-case of instruments for finer dissection; very easily sterilized. 
(About one-half reduction.) 






Fig. 52. — Various ways of wrapping linen twine, cut of proper length and ready for use. 



Fig. 53. — Formad's leather pocket-case for holding the instruments usually employed in making 
postmortem. (One-half natural size.) 





V 



I. 



I 



POST-MORTEM INSTRUMENTS AND THEIR USE 



39 



and in inches. Graduated calipers or a measuring stick (Fig. 47) may 
be used in determining diameters. Fig. 48 represents an instrument 
known as a raspatory. A metal pocket-case for instruments is shown 
in Fig. 49, and a leather one in Fig. 53. Graduated wooden cones 




tLXX..t.MJ..^J^.J^X M .i>X^LX^.^!| r Jp^qp.^^ 



Fig. 47. — Steel measuring stick marked in centimetres. (Reduced.) 

(Fig. 50) and glass balls (Fig. 51) are serviceable for measuring 
orifices and canals. Graduated measuring vessels of glass are useful. 
The larger vessels should be marked at every hundred cubic centi- 
metres up to one or two litres, and the smaller for every two cubic centi- 
metres up to a hundred. A stomach-pump is especially useful in with- 
drawing fluids from cavities. A urinometer is often of use. Ladles 
with a lip or spout, made of enamelled or agate ware, and with a 




Fig. 48.— Raspatory. (Reduced.) 



capacity of half a pint, or two hundred and fifty cubic centimetres, are 
needed in dipping fluid from cavities. A whetstone is useful, espe- 
cially the form with a handle and a leather strop on the back of the 
stone. (Fig. 21, jo.) A magnifying- glass that enlarges at least ten 
diameters should be in the hands of every one making postmortems. 
Other Supplies. — Enamelled trays or basins are useful for re- 
ceiving removed organs, and the basins are also required in cleansing 



40 



POST-MORTEM EXAMINATIONS 



the hands and instruments. Blocks of zvood are needed to support 
the body. Metal supports are unwieldy and scratch the table. The 
blocks should be made of very hard wood, as of ebony, were it not 
for the cost, it being most difficult to secure boxwood of the proper 
size. Some of these should be prismatic in form, others excavated 
to fit under the neck during removal of the brain. All wooden utensils 
should be finished with oil so as to be non-absorbent. Earthenware 
plates or wooden boards are useful during the dissection of organs. 
Needles (Fig. 21, j and 4) and coarse flax thread or fine twine are 
needed in closing incisions made through the skin. The thread is also 
required in ligating the intestines before removing them. Sponges are 
a necessity which are readily procured, and should always be moist 
when in use. Nauwerck keeps them in a creolin solution, but carbolic 
acid is better (two per cent.). F. W. Andrews 1 prepares a disinfecting 
solution by dissolving 37 grammes of ammonium persulphate, 
(NH 4 ) 2 S 2 8 , in 950 cubic centimetres of distilled water, and then 
adding 1 1 cubic centimetres of strong hydrochloric acid. The mixture 
when first made up has no extraordinary germicidal powers and must 
be allowed to stand for several days before using, when it will then 
appear as a perfectly clear solution and remain efficient for many 
weeks. The sponges are first thoroughly cleansed and become steril- 
ized within an hour after being placed in the mixture. Moreover, dis- 
colored sponges are bleached and renovated, a sojourn of two or three 
days in the mixture being requisite for this purpose. Pins are useful 
in fixing small structures in course of dissection. Special tables of 
zinc-covered wood, slate, iron, or glass are desirable in a pathologic 
department. Rotating tables are convenient, but weighing tables are 
expensive. The table should be constructed so as to carry off all 
fluids into a receptacle provided for them. (See p. 11.) 

Rubber gloves that reach well up the wrist and finger-cots afford 
protection to the pathologist, particularly in cases where the danger 
of infection is great. The gloves are more readily put on and are 
preserved by dusting them freely with ground soapstonz kept in a 
dusting bottle. (See p. 46.) Museum jars of various sizes or clean 
glass bottles with glass stoppers are useful for preserving gross speci- 
mens, and two-ounce, wide-mouth bottles, for microscopic specimens. 
Sealing-wax is needed to close the jar with after it has received the 

1 Lancet, October 14, 1905. 



POST-MORTEM INSTRUMENTS AND THEIR USE 4 j 

contents of the stomach in a case of poisoning in order to prevent its 
contents being tampered with. Bromin in a strong bottle with 
a ground-glass stopper that fits well serves a good purpose in disinfect- 
ing fresh wounds. Formaldehyd and distilled water should always be 
at hand. 

Pails are needed as containers for water and to receive fluid re- 
moved from the body. Cotton-wool, sawdust, or tow placed in the 
large cavities of the body before they are closed prevents the escape of 
fluid from them. An amusing story is told of a professor of pathology 
in Philadelphia whose assistant used a self-raising buckwheat flour for 
this purpose ; the formation of gas was so great that an explosion took 
place in the night. Plaster of Paris and sand serve similar purposes in 
the cranial cavity. Disinfectants and deodorants should not be for- 
gotten, as it is desirable to destroy or neutralize odors emanating from 
the body, and to disinfect and deodorize the hands of the pathologist 
after the examination has been completed. Bellows are occasionally 
useful in inflating viscera, as the lungs or stomach. A hand-bag which 
may be properly cleansed is often required for the carrying of the 
requisites to a postmortem. 

The chemic, bacteriologic, and microscopic supplies required in the 
work of the pathologist at the postmortem are red and blue litmus 
paper, turmeric paper, Lugol's solution, solution of sulphid of ammo- 
nium for detection of free iron derived from bile pigment (as in perni- 
cious anaemia), Gabbett's solution, carbol-fuchsin, Loffler's alkaline 
methylen blue, absolute and commercial alcohol, ethyl chlorid or methyl 
chlorid; culture tubes containing blood-serum, agar, and gelatin (bouil- 
lon is troublesome to carry) ; an alcohol-lamp, glass slides and covers 
for microscopic specimens, filter-papers three or four inches in diameter, 
an old scalpel which can be heated, a platinum wire three inches 
(eight centimetres) long, set in a solid glass rod six inches (fifteen 
centimetres) long, for making cultures (called an ose), 1 a microscope, 
a freezing microtome, and easy access to an incubator. A Paquelin 
thermocautery or one of the simpler forms now so commonly used 
for wood burning is very useful for bacteriologic purposes. 

In my own experience it has been found desirable or convenient 
to discard one instrument after another until now my satchel for 

1 Wetherill has recently suggested the use of an electric ose, the platinum wire 
being connected to a hand-battery of sufficient strength to cause the metal to glow 
when the current is turned on. 



42 



POST-MORTEM EXAMINATIONS 



private work weighs with its contents but ten pounds, and con- 
tains the following articles: two section-knives in good condition; 
a scalpel; a pair of medium-sized, strong scissors; a pair of bone- 
forceps; a dissecting forceps; a saw; an enterotome; a hammer 
with a hook on its handle; a pelvimeter; a new rubber catheter; 
gummed labels; various kinds of litmus paper; sealing-wax; a 
dissecting-apron and sleeves ; a pair of rubber gloves, with plenty of 
ground soapstone in an iodoform-dusting bottle; finger-stalls; a 
piece of thin rubber sheeting 30 by 45 inches; a square yard of 
oiled silk, or a rubber bag (10 by 16 inches) from which fluid 
will not escape; two medium-sized bath-sponges; a quart museum 
jar graduated into ounces or cubic centimetres, into which some of 
the smaller articles are placed and which can be used for the 
removal of gross specimens later, if desired; a large needle and flax 
twine, cut and wrapped (Fig. 52) into three lengths, for sewing the 
body with single thread (forty-five inches), for sewing the head 
(twenty-five inches), and for tying the intestines (ten inches) ; some 
bromin in a strong bottle with a well-fitting ground-glass stopper; 
two per cent, iodoform celloidin solution ; a small roll of cotton ; four 
two-ounce, wide-mouth bottles for microscopic specimens, one of 
which should be filled with seventy per cent, alcohol, one with ten per 
cent, formalin, one with Miiller's fluid, and the fourth with a saturated 
solution of mercuric bichlorid; two ounces of creolin; a cake of one 
per cent, bichlorid of mercury soap ; an ose ; an alcohol-lamp ; several 
culture-tubes properly packed; incense powders; matches; pins, 
safety and ordinary ; a steel tape measure marked in inches and centi- 
metres; a hand lens magnifying not less than ten diameters; spring 
scales weighing up to fifteen pounds; whetstone; an electric pocket 
lamp; and last, but not least, a note-book and several pencils, one of 
which will write on glass. To this list may be added other articles 
as the necessities of the case may demand or the individual ingenuity 
of the operator may suggest. 

For the private use of the general practitioner, a large section- 
knife, a scalpel, an enterotome, a saw, a chisel, a mallet, a pair of 
scissors, and a large needle may be purchased for about five dollars. 
These should be kept rolled up in a piece of chamois-skin, preferably 
made with pockets into which the instruments fit, and if the latter be 
put away clean after use they are always ready for service; or a 
leather case (Fig. 53) may be employed. 



POST-MORTEM INSTRUMENTS AND THEIR USE 



43 



In the U. S. Army the following post-mortem instruments are 
furnished in a mahogany box : 



Blowpipe No. I 

Chains and hooks No. I 

Chisel No. I 

Costotome chisel No. I 

Enterotome No. i 

Forceps, dissecting No. I 

Hammer, steel No. I 

Knife, amputating, large No. I 



Knife, amputating, small No. I 

Knife, cartilage No. I 

Needles and thread No. 2 

Saw No. 1 

Scalpels, assorted No. 3 

Scissors, straight No. 1 

Tenaculum No. 1 



In addition at the large hospitals, to which a pathologist is detailed, 
such other instruments are furnished as may be thought necessary, all 
stations, of course, being provided with sponges, basins, trays, etc. 
The medical department of the Navy supplies the same instruments as 
the Army with the exception that the large and small amputating 
knives are omitted and a director, a double-edge brain-knife, and a 
large aneurism needle are added. 

The proper handling of post-mortem instruments is not acquired 
in a day, and the beginner will find that experience teaches many les- 
sons which are not likely to be forgotten. A well-ground, keen-edged 
knife is a great desideratum, the advantage of a dull knife being 
simply that it is less likely to injure a beginner or careless operator and 
to disfigure the exposed portions of the body. 1 

In opening the body free incisions should be made by an easy, 
untrammelled movement, executed by the muscles of the shoulder 
rather than by those of the arm or hand. It is essential that the knife 
be grasped firmly (Fig. 54), and not held like a pen, as is a scalpel in 
the act of dissecting the finer structures of the body. Virchow says that 
the knife should be held in the whole hand, so that when the arm is 
stretched out the blade extends with it. The fingers and hands are 
fixed, if not absolutely, at least relatively, and the motion is executed 
with the whole arm, so that the movement is principally in the shoul- 
der-joint and secondarily in the elbow- joint. Thus the whole strength 
of the arm and shoulder muscles is brought into play and long, smooth 
incisions, so essential to proper inspection, are made. In cutting, pres- 
sure should be uniform, and the greater the pressure the quicker the 
knife should pass through the tissues. A clean cut made in the wrong 

1 The various methods of holding and using the instruments will be seen illus- 
trated by reference to the pages treating of the examination of the various organs. 



I 



44 POST-MORTEM EXAMINATIONS 

place does less harm than a ragged one in the right place (Virchow). 
The portion of the blade near the handle should be used for 
work which dulls a knife, as cutting the ribs. This also applies 
to scissors, the part near the pivot being employed in all cases in which 
considerable force is required. When the knife is held as shown in Fig. 
59 or 61, but preferably as in Fig. 61, the operator is sure to have a 
firm grasp of the knife-handle, so that there will be little likelihood of a 
dangerous slip. The actual cutting is properly and mainly done with 
the belly of the knife about one inch from its end, for which reason 
this part of the blade is always the thickest. The direction of the 
incision should invariably be from the operator, especial care being 
taken not to wound the left hand, and from those portions of the sub- 
ject in which disfigurement would be most likely to be noticed. Care 
must also be taken not to injure the assistants or those standing near. 
When the resistance of a tissue is unexpectedly overcome, the knife 
will sometimes travel a considerable distance before it can be stopped 
by an effort of the will. 

The blade of the knife must be kept free from blood by frequent 
washing. This is especially necessary when incising organs, as the 
brain, in which incisions are made with much more satisfaction if the 
knife-blade be previously moistened. A pointed knife may be used for 
the removal of the tongue and the larynx, and a scalpel for fine dis- 
section, as in tracing the spermatic or thoracic duct and the fourth 
cranial nerve. 



CHAPTER IV 

THE CARE OF THE HANDS AND THE TREATMENT OF POST-MORTEM 

WOUNDS 

Before beginning the autopsy, especially in a purulent case, the 
pathologist should carefully examine his hands; if these be not in 
good condition, the notes may be dictated by him while some one 
else is doing the actual cutting. All rings should be removed and 
the finger-nails cut close, except possibly those of the thumb and 
index-finger of one hand, which may be left slightly protruding in 
order to grasp certain parts, as the capsule of the kidney, to facilitate 
its removal, — a feat often difficult of accomplishment without the use 
of an instrument, such as a knife, when rubber gloves are used. 

Abrasions of the skin of the hands and forearms may be detected 
by the application of a ten per cent, solution of glacial acetic acid, 
which will at once reveal the location of such lesions by the smarting 
sensation that ensues. Slight wounds on the hands may be protected 
before beginning the necropsy by placing a small piece of absorbent 
cotton upon them and then applying the ordinary thick celloidin used 
in bacteriologic work, or the two per cent, iodoform celloidin already 
referred to. Varnish such as is used to coat pictures, liquid gutta- 
percha, or liquid court-plaster may also be employed for this purpose. 

It was once the custom for pathologists before making an autopsy 
to anoint their hands and forearms with some antiseptic salve, such as 
vaselin containing boric acid, ten grains to the ounce, a ten per cent, 
carbolic acid ointment, or an alcoholic solution of balsam of Peru. If 
these be used, they should be renewed several times during the 
postmortem. It is, however, doubtful whether the advantages gained 
by their employment are not more than offset by the fact that the 
hold upon the instruments is thereby rendered less secure. This can 
to a certain extent be avoided by fully anointing only the left hand 
(the one which handles the tissues) and the back of the right (the 
hand that holds the instruments), thus limiting the application of the 
protective to those parts through which infection usually takes place 
when no mechanical injury to the hands is inflicted. Frequent wash- 
ing of the hands in clean water is regarded by many as decidedly 

45 



4 6 POST-MORTEM EXAMINATIONS 

better. Of course, when digital investigations are necessary, as in 
exploring fistulous tracts, examining the vagina and os uteri, and in 
certain kinds of peritonitis, antiseptic unguents are desirable; in such 
cases it is necessary to anoint only that hand or portion of the hand 
which comes in contact with the tissues under investigation. It is also 
an advantage sometimes to introduce carbolized vaselin into the 
crevices around the finger-nails. 

An equally efficient and in many respects a much better safeguard 
against infection is the use of rubber gloves. Those should be selected 
which are neither too thick nor too thin, and not the old-fashioned 
thick black, red, or white gloves. They should be provided with 
long sleeves, and should be purchased from a reliable dealer who has 
not had them too long in stock, as they markedly deteriorate by age. 
They fit snugly, and are especially useful when opening the stomach 
and intestines, as it is most frequently the intestinal contents which 
impart the odor that adheres so persistently to the hands. They do 
not prevent, though they to a certain extent hinder, the production of 
post-mortem wounds. After use they should be washed both inside 
and out with water to which a little washing soda has been added 
and scrubbed with a nail-brush until clean, rubbed lightly with a towel 
or absorbent lint until thoroughly dried, and then carefully dusted 
with powdered soapstone or with talcum powder. Either the weight 
of the water or pressure of the air may be used to force the everted 
fingers straight. With care rubber gloves may be sterilized in the 
autoclave. They should never be put away moist or dirty. Small 
openings may be patched in the same manner as a bicycle or auto- 
mobile tire. Should the postmortem be upon a metallic poison case, 
a new pair of gloves should be used, and another pair from the same 
lot reserved unused for possible future examination by the chemist. 
Those of us who have made many hundreds of autopsies with our 
naked hands feel that we lose that delicacy of touch so desirable in 
post-mortem work when gloves are employed. Letulle, 1 in his recent 
work, enters into a tirade against their use. The coming generation 
will, however, undoubtedly wear them, or employ some such sub- 
stitute as that recommended by Murphy, 2 of Chicago, who has re- 
cently suggested a method of dispensing with gloves in surgical opera- 

1 La pratique des autopsies, 1903. 

3 Jr. Amer. Med. Assoc.,. September 17, 1904. 



TREATMENT OF POST-MORTEM WOUNDS 



47 



tions. This consists in the application to the hands of a four to eight 
per cent, solution of gutta-percha in benzin or acetone, the former 
giving the better satisfaction in routine practice, as it is more lasting. 
The coating may have to be renewed during the operation, and when 
removed, by washing in benzin, leaves the hands soft and smooth. 
Rubber finger-stalls, especially the variety known as the seamless 
rolled finger-cot, which unrolls as it is placed on the finger, are useful 
if the operator have any hangnails or other abrasions of the fingers. 
They often break, however, during the performance of the autopsy. 
Blood, pus, or other fluid should not be allowed to dry upon the 
hands, upon the gloves, or upon the instruments used. Upon the hands 
they not only impair the delicacy of touch so desirable in this work, 
but may also cause unsightly stains upon the skin, which are difficult 
to remove, especially when certain preservatives have been employed 
in embalming the body. Simmonds * uses a thin rubber coat, the 
sleeves of which overlap the rubber gloves, the point of contact being 
made watertight by an elastic band. 

The hands may usually be freed from odor by applying to them, 
while still wet, either a few drops of turpentine, formic aldehyd ( from 
one to two per cent.), aromatic spirit of ammonia, liquor antisepticus, 
U. S. Pharm., 1900, paregoric, or mustard, and then washing them 
thoroughly with a good glycerin soap. The use of equal parts of 
hypobromite solution (used in the quantitative estimation of urea) 
and of water, while severe, is also very effective for this purpose. A 
five per cent, chloral hydrate solution may also be employed. 

For disinfection of the hands after the postmortem one may 
use a creolin solution, made by placing about an ounce of creolin in 
a basin of tepid water ; 2 a mixture of two teaspoonfuls of acetic acid, 
twice this amount of calx chlorinata, and a quart of water; bi- 
chlorid solution 1 to 1000; ninety per cent, alcohol; or a concen- 
trated solution of potassium permanganate. The brownish discolora- 
tion of the hands may be removed by applying to them while still moist 
either oxalic acid or a concentrated aqueous solution of the bisul- 
phite of sodium to which has been added a small amount of chlorin; 
or an antiseptic soap may be employed. Of the latter, I prefer the 
one per cent, bichlorid of mercury soap, or a ten per cent, lysol 

1 Centralbl. f. allg. Path. u. path. Anat., 1906, vol. xvii, no. I. 

2 Or, more exactly, a two per cent, creolin solution. 






48 POST-MORTEM EXAMINATIONS 

solution made with the tincture of green soap. Of course, any of 
the surgical methods in vogue for disinfection of the hands may be 
employed. Hand brushes may be kept in five per cent, formalin solu- 
tion, as this keeps the bristles stiff and clean. At the end a sodium 
bicarbonate wash and the application of a little lemon juice leave 
the hands in good condition. A brisk walk in the open air is also to 
be advised after the completion of the autopsy. 

A post-mortem wound, as usually referred to, means not only a 
break in the continuity of the skin by an accidental incision, puncture, 
or other injury received at an autopsy, but also the inoculation therein 
of pathogenic bacteria from the cadaver, and their subsequent multi- 
plication in the system, with the production of toxic symptoms. 
Wounds presenting similar characteristics may, of course, be derived 
from many sources, as from surgical operations or from other post- 
mortem wounds. The intact skin of the hand is a perfect protective 
against the invasion of bacteria. In order that the organisms may 
infect the body, there must be both a point of entrance and a pre- 
disposition or lack of immunity in the individual affected. While 
any of the infectious diseases may be contracted in making a post- 
mortem, those most to be feared are tuberculous warts, syphilis, 1 
gonorrhceal ophthalmia, tetanus, anthrax, glanders, plague, actino- 
mycosis, typhus fever, yellow fever, cholera, and smallpox. I have 
seen septicaemia, general tuberculosis, ulcerative endocarditis, puru- 
lent meningitis, boils, whitlows, etc., follow post-mortem wounds. 
Several years ago one of my patients suffered from a tuberculous wart 
which he had evidently contracted from a cow, thus adding another 
case to the list of those affected with bovine tuberculosis. 

The results of a post-mortem wound depend very much upon the 
general health of the one affected, and experience seems to show that 
severer symptoms and slower convalescence may be expected in those 
who are habituated to the use of alcohol. Inoculations from serous 
surfaces are especially to be guarded against, as from some of the 
varieties of peritonitis due to criminal abortion, and other forms of 



1 J. de Lisle (Amer. Med., Sept. 19, 1903) writes, "Medical records furnish no 
instance of a specific contamination resulting from a wound received during the 
autopsy of a syphilitic cadaver." Blaschko (Berl. klin. Wchnschr., 1904, vol. xli, 
no. 52) reports a case of syphilitic infection unmistakably derived from the dissec- 
tion of a syphilitic cadaver twenty-four hours after death. The Microspironema 
pallidum has also been found at autopsy. 



TREATMENT OF POST-MORTEM WOUNDS 49 

septic peritonitis, meningitis, or pleurisy. Among other virulent kinds 
of post-mortem wounds may be mentioned those derived from cases 
of pyaemia, of septicaemia, of puerperal fever, of malignant oedema 
and diffuse cellulitis, of erysipelas, and of gangrene. Infection by 
the Bacterium pyocyaneum may cause long-continued high temperature 
with little local manifestation, as in my own case when I became 
inoculated with this organism from a case of cancer of the gall- 
bladder with secondary infection by this bacillus. 

It is often asked why post-mortem wounds and injuries received 
in the performance of similar operations are more dangerous than 
those which are otherwise inflicted, though containing the same 
organism. Their greater virulence may in part be due to the fact 
that they are usually punctured wounds, in which the organisms are 
implanted deeply in the tissues, especially in cases of tetanus, which 
is due to an anaerobic bacillus. Again, it is well known that many 
organisms become more virulent by passing through successive 
animals, and, therefore, an organism which has overcome the resistance 
of the tissues and killed them is naturally more destructive than one 
which has not had such favorable opportunities for growth. It has 
been shown experimentally that bone-marrow possesses marked bac- 
tericidal properties. It is a well-established clinical fact that wounds 
produced by sharp spicules of bone are unusually severe. The reason 
assigned is that bacteria which have already overcome the increased 
resistance of the bone-marrow have now been introduced into the body. 

Post-mortem wounds are generally caused in one of four ways: 
first, by the operator injuring himself with instruments used in the 
making of the autopsy, especially sharp-pointed knives and the saw; 
second, by scratches or punctures from ragged bones or calcified 
tissues, as the ribs or atheromatous patches of the aorta which have 
undergone calcareous infiltration; third, by inoculation of pre-exist- 
ing wounds, abrasions, small eruptions, especially at the roots of the 
hair-follicles, hangnails, blisters, fissures in chapped hands, by infec- 
tion from unsterilized instruments, by subsequent injuries received 
upon unsterilized hands, etc. ; and, fourth, by cuts and scratches acci- 
dentally inflicted by the operator on his assistant, as in opening the 
head. Indeed, so frequently does the latter occur that a helper to 
steady the head should be dispensed with unless his hands be thor- 
oughly protected by some covering, such as a towel. Some of the 
usual ways of producing wounds which are especially worthy of men- 

4 



50 POST-MORTEM EXAMINATIONS 

tion are by the operator cutting towards instead of away from himself 
or his assistant; by leaving a knife in one of the cavities and for- 
getting its presence; by placing his instruments in a dangerous posi- 
tion on the body, the table, or the ice-box; by the use of sharp-pointed 
knives; by punctures from the needle made during the sewing up 
of the body; and by the too rapid passage of thread through the 
hands, producing a sort of brush-burn. Ragged wounds, such as 
those caused by the saw or by bones, are especially to be dreaded, for, 
being both punctured and lacerated, they easily become infected. 

The micro-organisms present at a postmortem made several days 
after death are apt to be less virulent than those encountered soon after 
dissolution, the saprophytes having now gained the mastery. Other 
things being equal, the more quickly the patient died after infection, the 
more dangerous will be the post-mortem wound ; but the character of 
this lesion and the nature of the organism must always be considered. 
Undoubtedly, persons making many postmortems become immune to 
inoculation by the ordinary Staphylococci and Streptococci. When 
toxins are introduced along with the bacteria, the constitutional symp- 
toms are apt to be more severe, as the toxins overcome a certain 
amount of vital force at the point of infection of the tissues which 
would otherwise aid in combating the micro-organisms. 

As is well known, the bleeding of a wound is a considerable pro- 
tection thereto; hence its immediate closure by the application of 
caustics or of celloidin is worse than useless. If the finger be 
wounded, it should be wrapped with a miniature Esmarch band and 
allowed to bleed freely under running water for at least five min- 
utes, or the part may be washed in distilled water made alkaline by 
the addition of sodium bicarbonate, cleansed with equal parts of 
alcohol and ether, and then washed with an antiseptic solution. Suck- 
ing of the wound after cleansing has been practised. If a caustic 
be used, there is probably nothing better than glacial acetic acid, 
carbolic acid, or pure bromin. The employment of the actual cautery 
is advisable in some cases, but it must be so thoroughly applied that 
no pathogenic organisms are left behind, as otherwise the necrosed 
tissue affords a favorable medium for their growth. A fifty per cent. 
alcoholic dressing, moist mercuric bichlorid gauze, or dry sterile gauze 
is now applied, which should be renewed twice daily. On the slight- 
est indication of pus or a deadish-gray appearance of the edges 
of the wound, it should be freely incised, thoroughly curetted, cleansed 



TREATMENT OF POST-MORTEM WOUNDS 



51 



with a sterile .salt solution, dusted with iodoform, and protected with 
a wet bichlorid dressing ; or a solution of silver nitrate may be applied 
with benefit. I have seen no good effect from the local use of the 
unguentum Crede (ointment of fifteen per cent, soluble metallic 
silver). The frequent application of hot flaxseed poultices contain- 
ing a teaspoonful of Labarraque's solution is most grateful when the 
wound is discharging. Several inches above the wound a ring of iodin 
should be plentifully painted. Intravenous injections of antitoxic sera, 
collargol, formalin, and silver nitrate have been practised by some with 
alleged benefit in septic affections. Hume injects intravenously five 
hundred cubic centimetres of water containing one-half cubic centi- 
metre of a ten per cent, solution of the nitrate of silver at a tem- 
perature of from no° F. to 115 F. 

Involvement of the lymphatics, as manifested by red lines run- 
ning up the arm, usually on the inner surface, and tenderness in the 
axilla, indicates danger, and shows that the infection is no longer a 
local one. Inflammation of the lymphatics of the axilla may cause 
the glands in this region to become tender and enlarged, so that an 
incision is necessary; and in cases of axillary cellulitis, even though 
the wound of inoculation be small, early opening should be employed. 
Quinine is useful in these cases, and phosphoric acid and iron may 
be prescribed later. The affected arm should be carried in a sling, 
tonic treatment with changes of air instituted, and a surgeon con- 
sulted, who will treat the case according to the character of the 
wound, the nature of the infection, and the constitution of the patient. 
When healing has begun, massage has made many a serviceable finger 
or hand out of what would otherwise have been a stiff and useless one. 

The anatomic wart is a local tuberculous lesion, often multiple, 
and is usually situated on the back of the hand or at the inner joints 
of the fingers. There is a warty thickening of the papillae of the 
skin, accompanied by a discharge of thin serous pus, but with no true 
ulceration. The sensation produced is similar to that caused by a 
splinter, which, however, subsides for several days after the removal 
of the fluid contents. The lesion sometimes heals spontaneously, but 
may give rise, as in the case of one of my helpers in the post-mortem 
room at Blockley, to general tuberculosis. Wet dressings, combined 
with an application of equal parts of glycerin and extract of belladonna, 
may be emplo}^ed, or the following mixture applied: Salicylic acid, 
10 parts; extract of cannabis indica, cocaine hydrochlorate, of each 1 






52 



POST-MORTEM EXAMINATIONS 



part; oil of turpentine, 5 parts; glacial acetic acid, 2 parts; and 
collodion, 100 parts. It would be interesting to try the hypodermic 
injection of tuberculin, or some of the newer forms of treatment of 
lupus of the face, as that of the concentrated rays of light recommended 
by Finsen. In one of my cases treated by the X-rays in 1896 I thought 
that an anatomic wart was rendered worse by their use. When tuber- 
culous warts have lasted several months, surgical treatment should be 
instituted, care being taken to remove them in their entirety without 
cutting into the diseased area. Guinea-pigs injected with such material, 
which contain but few bacilli, usually linger a long time ; in one of my 
cases over six months elapsed before the animal died from general 
tuberculosis of a fibroid nature. 

Suppuration of the matrix of the nails can often be cured only 
by the removal of the nail, though frequent soaking of the finger in 
a hot saturated solution of boric acid or a strong solution of lead sub- 
acetate may be tried. Or the nail may be soaked in a solution of silver 
nitrate — twenty grains or more to the ounce — and then wrapped in a 
moist bichlorid of mercury dressing. Dropping upon the wound a 
saturated solution of iodoform in ether has also been tried. Diffuse 
cellulitis should be treated by early and free incision and by the applica- 
tion of compresses. When the hand itself is involved in spreading 
gangrene, amputation should usually be practised. If tetanus is feared, 
the wound should be laid open and the area of contagion, if possible, re- 
moved, powdered antitoxin applied to the part, and the general health 
of the patient sustained. The subdural use of the antitoxin and, better 
still, direct injection into the spinal canal have recently been employed. 

If the knives used in post-mortem work were thoroughly sterilized 
after each necropsy, there would be fewer infected wounds. For this 
purpose they should be boiled for five minutes after use in a one 
per cent, soda solution, the edge of the knife being protected, as by 
wrapping in cloth, so as not to dull it. Entres recommends one-half 
per cent, formalin or the use of tablets of mercury oxycyanide 1 to 1000. 
The making of autopsies is undoubtedly dangerous, and therefore those 
who perform them frequently should insure themselves in one or other 
of the accident companies which contain a clause giving a claim for 
benefits in case of wound-infection. As these companies generally show 
a marked disposition to dispute claims, every injury, no matter how 
slight, should be reported to them as soon as possible after its occur- 
rence, so that any subsequent damages may be easily proved. 



CHAPTER V 

EXAMINATION OF THE EXTERIOR OF THE BODY 

Signs of Death. — The signs of death are of two kinds, — those 
which manifest themselves immediately upon the extinction of life 
and those which appear only after the lapse of a shorter or longer 
period of time, and vary at the time of dissolution according to the 
age, muscular state of the body, disease, presence of certain poisons, 
etc., and the external conditions surrounding the body. The later signs 
are the more positive, but the earlier ones are of more importance from 
a utilitarian point of view. Taken individually, each sign may be 
inconclusive, but when considered collectively they give a scientific 
authority to the generally only too apparent fact that death has taken 
place. Cases of trance and the Indian fakirs afford the best illustra- 
tions of suspended animation. Authentic instances of persons having 
been buried alive during suspended animation are almost unknown, 1 
investigation of the newspaper accounts of such premature interments 
in almost every instance showing their falsity. In Munich the popular 
belief in such occurrences is so great that the bodies .of those dying 
in the higher walks of life are kept for several days previous to burial 
in a specially prepared room, a bell being placed in the hands of the 
corpse for the purpose of summoning an attendant in case of resuscita- 
tion. Such notions usually originate from careless handling of the 
coffin, from the expulsion of a fcetus by the formation of gases in the 
body of a pregnant woman, from real or apparent growth of hair, 
from conversion of bodies into adipocere, etc. In a judicial hanging 
the murderer is ordered to be hung by the neck until he is dead. The 
responsibility of fixing this time naturally devolves upon the physician. 
It was recently brought out at an inquest held in England that 
a child nine days old was pronounced dead by a physician after 
twenty minutes of observation ; the child was later on discovered to be 
living and remained so for over eighteen hours. 

It is not possible to draw a sharp line between physiologic and 
pathologic death. Even when what we call " death" has taken place, 
the function of all organs has not ceased, the most important organs, 

1 See Icard, Presse med., no. 66, 1904. 

53 



54 POST-MORTEM EXAMINATIONS 

heart, lungs, and nervous system, sometimes continuing their activity. 
Functionating of the intestinal tract, liver, and kidneys may cease 
and yet the patient live several days before death ensue. The senses 
may be lost without ending life. 

The earlier or negative indications of death are, first of all, insensi- 
bility and inability to move, often preceded by the so-called death-rattle. 
There are loss of sensitiveness to stimuli, loss of reflexes, failure to 
respond to inflammation, and the cessation of all bodily vitality, though 
in cases of sudden death spermatozoa may be found in movement 
twenty-four hours after decease and atropine will dilate and physo- 
stigmine will contract the pupils as long as molecular life exists in the 
ocular tissues. Loss of nervous and muscular irritability is determined 
by application of light to the eye, of snuff to the nose, or of cold, heat, 
force, electricity, or other irritants to the skin. Rosenthal considers the 
existence of electric contractility in a dead body to be an indication that 
death has taken place within two or three hours. After the head is sev- 
ered by the guillotine the eyes may open and close and in amputated 
limbs muscular twitchings may often be seen even for hours after their 
complete removal from the body. Associated with the change in mus- 
cular tonicity is the facial expression. During the period of relaxa- 
tion the visage is pale and flaccid, except in very rare cases, where the 
face even immediately before death has a red color and there is a 
drawn, contracted, painful expression, the so-called fades Hippocratica. 

Much more positive signs are the entire and continuous cessation 
of the respiration and circulation. As a rule, respiration stops a 
moment or so before the heart-throbs and ceases sooner in infants 
than in adults. The absence of breathing may be determined by 
auscultation and by the lack of motion of a down feather or small 
flame or by the absence of the deposition of moisture on a cold mirror 
held before the lips. A glass of water or of mercury placed upon 
the epigastrium will show a ripple on its surface if there be the slight- 
est movement of respiration (Winslow's test). The X-rays have also 
been used to detect any activity of the heart and lungs. 

Most of the minor signs of death depend upon the absence of 
circulation. This is determined first by observation. The skin of a 
dead person acquires almost immediately a leaden pallor or lividity 
and loses its translucency. The mucous membranes become pale and 
exsanguinated. The hands if viewed by strong transmitted light show 
no pink tinge where the fingers come in contact (diaphanous test). 

: . ■*._ :'v. 



EXAMINATION OF THE EXTERIOR OF THE BODY 



55 



The palms and soles of the feet become more or less yellow in color. 
By palpation and auscultation the absence of pulse and heart-beat can 
be determined. A small artery, as the temporal, may be incised and 
examined; after death it will be found empty and its lining will be 
of a pale-yellow color. The mercury in the manometer records zero. 
Scarification or cupping on a dead subject causes no flow of blood, 
while ammonia injected subcutaneously produces no congestion. In 
Icard's test 1 fluorescin (resorcin-phthalein) is injected subcuta- 
neously; if life be present, greenish discoloration of the skin, mucous 
membranes, and eyes soon appears and the staining material may be 
chemically detected in blood abstracted at a distance from the point of 
injection. A tight ligature around a finger, a limb, or the lobe of an 
ear will give rise to no reddening (Magnus's test). Pressure applied 
to a finger-nail will drive the blood away, leaving a white area, which 
will again be filled with blood if there is any circulation. If a flame 
or heat of any kind, as from melted sealing-wax, is applied to the 
skin, and a vesicle is formed, the blister on the dead skin will contain 
a non-albuminous fluid and the underlying cutis vera will remain dry 
and glazed, while in the living the contents will be rich in albumin 
and the cutis vera will be reddened. Caustics applied to dead skin 
will form no eschar, but may make the skin yellow and transparent. A 
steel needle plunged into a muscle after death has occurred will not 
be oxidized, even though it remain in place for many hours, but would 
tarnish in ten seconds if life were present (Glaister). Brissemoret and 
Ambard 2 assert that the viscera, especially the liver and spleen, 
rapidly lose their normal alkaline reaction and become acid after 
death, even within a quarter of an hour after dissolution. The blood 
of the part should be removed, as far as possible, before testing. 

Besides these tests, there are changes in the eyes which are very 
important signs, and are in a great measure due to the loss of circula- 
tion, and later on to the evaporation of fluids, especially if the eyes be 
not closed. The fundus oculi is of a pale-yellowish white and its vessels 
are empty or the column of blood in them is beaded by the presence 
of bubbles of gas. There is a marked loss of elasticity in the eyelids 
and in the globe. The eye collapses, sinks back in the socket, and ap- 
pears flat and wrinkled, due to the loss of the vitreous and aqueous 
humors; it loses its lustre and presents a glazed appearance. In 

1 Le danger de la mort apparente sur les champs de bataille, Paris, 1903. 

2 Vircho-ufs Archiv, vol. clxxviii, no. 1. 



56 POST-MORTEM EXAMINATIONS 

some cases it is soft and flabby and may be covered with viscid 
mucus ; more rarely, as in apoplexy or hydrocyanic acid and carbonic 
acid poisoning, it remains bright, full, and prominent for a con- 
siderable time. The conjunctiva quickly becomes cloudy and gray. 
The cornea may become opaque immediately after death or during the 
last hours of life; in other cases it does not change until the lapse of 
several hours. The cornea, iris, and conjunctiva lose their sensitive- 
ness. In the last agony or shortly after death the pupils dilate, and 
again in about an hour they contract, as a rule unequally; this con- 
traction lasts for three or four days. The loss of elasticity in the eye is 
very marked; the pupil can be made oval and will remain oval by 
synchronously compressing the globe (Ripault's test). This may, 
however, occur before death. In most cases death occurs with the 
eyes and mouth open. This rule holds good especially in asphyxiation 
and sudden death, while in coma the eyes may remain closed. Owing 
to the unclosed eyelids, the sclerotic is exposed to the air and permits 
the water to evaporate, thus forming a dark oval stain on the temporal 
side of each globe (Larcher's sign). 

Another sign is loss of vital warmth (algor mortis). This occurs 
more rapidly at first than on nearing the temperature of the sur- 
rounding atmosphere. Clothing, fat, etc., cause the lowering to take 
place more slowly. Wilks and Taylor show that at an average tem- 
perature a nude dead body cools at the rate of about one degree 
Fahrenheit per hour. A body placed in water will cool more rapidly 
than in air of a similar temperature, and refrigerants naturally 
reduce the temperature quickly. Nysten finds 1 that the bodies of 
those killed by lightning or by suffocation retain their heat longer 
than when death is due to other causes. Post-mortem cooling requires 
under normal conditions, as a rule, twenty-three hours for its com- 
pletion. Brouardel says that the rectal temperature ordinarily is the 
same as that of the room in about forty hours. In the bodies of those 
who have died from some of the zymotic diseases, as cholera, tetanus, 
variola, etc., from injuries to the nervous system, or from certain 
abdominal disorders, the temperature may rise soon after death, and 
an elevation has also been noted during the period of muscular rigidity. 
Where decease is due to some chronic affection chilling is slow, while 
after fatal hemorrhage it is very rapid. 

1 Arch. gen. de med., June, 1862. 



EXAMINATION OF THE EXTERIOR OF THE BODY -7 

Decomposition. — The most positive sign of death is putrefaction, 
which appears as rigidity passes off after a longer or shorter time, and 
manifests itself first by a foul odor and a prominence of the superficial 
veins and by a greenish color in the iliac fossae and the centre of the 
abdomen, later on in the genitalia and thighs. Finally the whole 
body is involved. It becomes purplish red in color, due to the 
posthumous circulation, which is a displacement of the blood from the 
heart and large vessels by the pressure of the gases of putrefaction 
formed in the abdomen. The tissues soften and are more easily torn. 
Putrefaction succeeds death by snake poisoning at once, because it 
fixes itself to one of the factors (complement) which render the 
fluids of the body non-bacteriolytic. (Flexner.) Mummification and 
adipocere show that death took place some time ago. The bodies of 
infants decompose more quickly than those of adults. The process 
begins earlier in plethoric and fat adult bodies than in thin, aged per- 
sons. It is more rapid after muscular activity and in those dead of 
acute diseases, fevers, jaundice, heat-stroke, sepsis, suffocation by 
gases, etc., while it is longer delayed in cases where the system is 
exhausted and muscular irritability retarded, and in the bodies of 
those fatally poisoned by hydrocyanic acid, carbonic acid, sulphuric 
acid, etc. Arsenic may or may not prevent decomposition. At the 
same temperature a body which has been for one week in the air, 
one which has been two weeks in water, and one which has been eight 
weeks buried will show similar degrees of decomposition. (Brown- 
Sequard. ) In the cases of Hickman and Holland the kidneys of cer- 
tain exhumed bodies had resisted the agents of disintegration to a 
greater extent than had the uterus. 1 

Hofmann recommends, in cases where decomposition is much ad- 
vanced, the removal of the brain in the ordinary manner, the making of 
some openings in the skin, the washing of the entire body in running 
water for twelve hours, and the further bathing of the corpse in a con- 
centrated alcoholic sublimate solution or chlorid of zinc for an equal 
period. The green coloration due to decomposition disappears to a 
marked degree under this treatment. 

Post-Mortem or Cadaveric Lividity ; Hypostasis or Hypo- 
static Congestion (Livores mortis). — Unless drained of its blood by 
previous hemorrhage, a corpse usually shows a bluish-red to purplish- 

1 Lancet, December 26, 1903, p. 1797. 



, 



58 POST-MORTEM EXAMINATIONS 

red discoloration on its most dependent parts, due to the cessation of the 
circulation and to the gravitation of the blood to those organs. The 
discoloration does not, however, appear upon those portions of the body 
upon which it directly rests. It will at once be seen that this fact may 
afford a basis upon which to form an opinion as to the position in which 
a body has lain after death. Cyanotic changes, as in the fingers and 
toes, may remain after death. Post-mortem lividity rarely comes on 
before five hours ; though it may start even before death, as in cholera. 
It reaches its maximum in the second day and shows itself not 
only on the exterior of the body, but also on the dependent parts of 
such internal organs as the posterior wall of the stomach and the 
temporal lobes of the brain. Cadaveric lividity may resemble a bruise 
made during life, with all its various forms and shades of color. The 
distinguishing features are: (i) The discoloration in post-mortem 
lividity disappears on pressure, while that due to a bruise does not. 
(2) A patch of post-mortem lividity will bleed freely when incised, 
because the vessels in the dependent parts are engorged with blood, 
while from a bruise there is little or no oozing, as the original hemor- 
rhage is circumscribed and the discoloration is due to extravasated 
staining of the tissues and not to the actual presence of blood. The 
epidermis prevents the drying of the skin; when this is removed, 
leathery patches are seen. An incision into the affected area should 
therefore be made in all suspected cases, especially in those of a 
medicolegal character. If the part be washed with running water, 
blood will appear again and again in hypostatic congestion. The 
two conditions are more closely simulated in those rare cases of 
hypostasis where we find a post-mortem cedematous infiltration 
and enlargement of the adjacent tissue. Should such exist or 
should the two conditions be combined, it is well to free the 
suspected area from the hypostatic congestion by turning the body on 
the opposite side for several hours before describing the bruise. As 
a rule, the more fluid the blood, as in cases of death from suffocation, 
the acute infectious fevers, poisoning by hydrocyanic acid, etc., the 
more marked will be the post-mortem lividity. In the latter case, as 
well as in poisoning by illuminating gas, the lividity may be of a char- 
acteristic rose-red color. In potassium chlorate poisoning it is choco- 
late colored. In the negro the effects of cadaveric lividity are naturally 
more difficult of determination than in the white race. 



EXAMINATION OF THE EXTERIOR OF THE BODY $g 

Post-Mortem Rigidity or Death-Stiffening. — The involun- 
tary muscles first show contraction, — eyelids and heart 1 primarily, — 
and it is doubtless this action which sometimes causes the expulsion of 
a foetus after death. Post-mortem rigidity commences externally 
in the muscles of the lower jaw and neck and spreads downward, 
disappearing in the same order, though Lacher, from an examina- 
tion of six hundred bodies, found the condition to occur last in the 
arms. In ordinary cases it begins about two hours after death, is 
complete in from seven to eighteen hours, and ends as the stage of 
putrefaction comes on, in three or four days. Brown-Sequard men- 
tions a case of typhoid fever where rigidity came on in less than four 
minutes, disappeared in a quarter of an hour, and putrefaction com- 
menced in one hour after death. The stronger the individual and the 
shorter the duration of the fatal disease, the more prompt and marked 
usually will be the rigidity. The bodies of soldiers killed by 
being shot in battle after forced marches sometimes retain the 
position they occupied when they were hit, in certain cases even 
remaining erect when killed standing. The case of Captain Nolan 
at Balaklava is often cited in this connection, where it is alleged 
that he held a sword and with extended arm rode on horseback 
in the charge after death had ensued. The position of the hands 
produced by this muscular rigidity is also an important sign. The 
thumbs are usually flexed across the palms and the fingers flexed 
over the thumbs. Instantaneous rigor of the hand of a suicide may 
occur, a weapon being grasped tightly in the hand. This condition 
cannot be reproduced artificially, and shows high mental tension, 
nerve excitement, suicide, and not murder. Rigidity is marked, espe- 
cially in the abdominal muscles, after death from cholera. De la 
Camp 2 has shown by X-ray studies that the heart contracts in all 
directions and that the auriculoventricular openings may be closed 
thereby, but not before sufficient time has elapsed for blood to pass 
from the ventricles to the auricles. Rigidity is also seen at the 
pylorus and in an hypertrophied bladder. The body of one who 
has died from tetanus, strychnine, or other spinal poison, as vera- 
trum viride, may lie supported only by the head and heels, or 
when placed upright may stand erect with little or no support. In one 

1 Fuchs, Ztschr. f. Heilk. Abthl. path. Anat., 1900, p. 1. 
2 Ztschr. f. klin. Med., 1903, vol. xlix, p. 411. 



6o POST-MORTEM EXAMINATIONS 

of my cases of strychnine poisoning rigor mortis was present on dis- 
interment twenty-four days after death. Suffocation causes long-con- 
tinued post-mortem rigidity. Chronic alcoholism delays and prolongs 
it. The more muscular the individual, the slower is it in coming 
on and the longer in going off. Rigidity disappears more quickly in 
cachectic subjects, and is sometimes almost entirely absent after heat- 
stroke. The process does not depend upon the nervous system, but 
upon changes taking place in the sheaths of the individual muscular 
fibres. Section of the ischiatic nerves will delay, but not prevent, rigidity 
of the legs. 1 Laceration of muscles retards or may even prevent it. 
The reaction of the muscles is at first acid, due to sarcolactic and 
other acids (sarcomere). 2 - As the rigor mortis passes off the parts 
become alkaline, a condition natural to a decomposing body. It should 
be remembered that in the preparation of the body by the undertaker 
the rigidity may have been overcome by force; this is especially 
true of the elbows. On the other hand, be not deceived by a 
previously existing ankylosis. Rigidity may be overcome by the use 
of hot applications, but when it has once disappeared it seldom returns 
and is never again so pronounced as at first. Rapid cooling delays 
rigidity, which, however, passes off the more quickly when the body 
is once more made warm. This condition must be differentiated from 
freezing, where on reduction there is a crackling sound. Rigidity is not 
found in the immature foetus. Evidence of the limbs and body existing 
in a state of cadaveric rigidity in the shape in which the child is 
moulded in utero is strong proof of still-birth. 3 

Bodies which have been kept for a long time (or a shorter time 
under unfavorable conditions) after death, especially during cold 
weather, present another form of cadaveric lividity which is charac- 
terized by a uniform reddish tint. This is caused by the diffusion of 
haemoglobin from the blood-vessels into the surrounding tissues (im- 
bibition). This form of lividity is most conspicuous along the course 
of the superficial veins and is not affected by pressure. Haemolysis 
(disintegration of the blood) starts earliest in the portal vein (Reven- 
storf), aerated blood showing it last of all. In drowning this order is 
reversed. It is important to distinguish between post-mortem lividity 



1 Bierfreund, Arch, f. d. ges. Phys., 1888. 

2 Bruecke, Kuhne; quoted from Ziegler's Gen. Path., xi ed., p. 179. 

3 Brit. Med. Jour.; N. Y. State Jr., June, 1905, p. 216. 



EXAMINATION OF THE EXTERIOR OF THE BODY 6 1 

and the greenish discoloration of commencing decomposition, usually 
first seen over the abdomen. According to some authorities, the green- 
ish color is due to the precipitation of the iron of the haemoglobin by the 
hydrogen sulphid arising from the decomposition of the tissues under 
the influence of bacteria, while others teach that it is due to chromo- 
genic organisms themselves or a pigment elaborated by them of iron, 
potassium, and cyanogen. In one of my cases such discoloration was 
mistaken for the effects of personal violence, and serious allegations 
based upon this error were made against the husband of the deceased. 

The length of time which has elapsed since death has to be deter- 
mined by the circumstances peculiar to each case. So many considera- 
tions may apply that in many instances it is dangerous to be too 
dogmatic. 

External Examination of the Body. — It is of great impor- 
tance that we should not confine ourselves solely to the examination 
of the corpse, but should, in addition, carefully scrutinize the clinical 
history, weigh the evidence derived from a personal survey of the 
surroundings, consider the circumstances under which death occurred, 
and question the persons who came in contact with the subject just 
before and after death. Data derived from such sources are of especial 
value in medicolegal cases or when a postmortem is to be performed 
upon an unidentified body ; but the knowledge acquired by inspecting 
the surroundings and the exterior of the cadaver must in no way bias 
the operator before the internal examination is made, as the unex- 
pected may happen here as well as elsewhere. The naked body is 
then to be minutely inspected, first as a whole for symmetry and then 
both anteriorly and posteriorly as to its component parts, proceeding 
in a definite and orderly manner. It would indeed be to our advan- 
tage in acquiring pathologic knowledge if the living body in the nude 
state were more frequently made the subject of careful study, for the 
information thus obtained is often of the greatest value to the clinician 
and surgeon. 

Identification of the Body. — Before a postmortem is begun, 
the remains should, if practicable, be positively identified to the 
obducent by one or more persons who knew the individual during life. 
If this be impossible, the one who found the cadaver or those who 
saw it in its original situation after death and those that removed it 
from one place to another may act as identifiers. Persons who have 
gone under several names should be recorded under their legally 



62 POST-MORTEM EXAMINATIONS 

correct names, any aliases which had been used being also recorded. 
Certain details, such as articles of clothing, jewelry, and even pawn 
tickets, sex, age, height, weight, birth-marks, angioma, moles, tattoo 
markings, condition of the teeth, anomalies of the ear and eye, deformi- 
ties, wounds, scars, or even the evidence of certain diseases, are of 
great importance and may often be the sole means of identifying the 
body. Should personal identification be impossible, a cast of the face, 
a photograph, and an accurate description of the body, with a full and 
clear statement of any peculiarities, should be made. In some cases 
a wax cast of the interior of the mouth, made afterwards in plaster, 
may be helpful. A set of false teeth or glasses should be preserved. 
As the person whose body is being examined may have been 
a criminal and thus during life have had the Bertillon system 
applied for purposes of future identification, these measurements 
and finger-impressions should be secured in important cases. 1 Skia- 
graphs of old osseous lesions, as well as a record of the teeth of 
the decedent and of their peculiarities, might also lead to identifica- 
tion. Clothing alone is not sufficient for purposes of identification, as 
bodies have been substituted and clothed in the wearing apparel of the 
alleged deceased, such substitutions being made in order to defraud 
life-insurance companies or change succession to titles and estates. 
The body of Admiral Paul Jones was identified in Paris one hundred 
and thirteen years after his death. A bust executed from life and a 
knowledge of his age and physical condition were the means of identi- 
fication, coupled with a fair presumption of his place of burial. The 
corpse was that of a man forty-five years old with brown hair slightly 
turned gray. The body was well preserved in spirits in a leaden coffin. 
Chronic bronchial pneumonia and advanced interstitial nephritis were 
found. Admiral Jones was known to have had serious pulmonary 
symptoms and oedema of the lower extremities. Lortet recently 
examined microscopically the heart of Rameses II, who died 1273 b.c. 
Care of Clothing and a Study of the Surroundings. — The 
clothes may greatly assist the legal authorities in the prosecution of a 
case, as in showing the entrance but not the exit of a bullet. In such 

1 A recent case in England showed that the right thumb of one of the prisoners 
agreed with the marks left behind at the time of the robbery, there being twelve 
characteristics in common. Collins, of Scotland Yard, stated in the trial that only 
in two or three out of 80,000 cases had he found three characteristics to agree. 



EXAMINATION OF THE EXTERIOR OF THE BODY 



63 



cases, where the clothing has not been already removed by responsible 
persons before the arrival of the physician, as is done in certain places 
(though this is scarcely justifiable), the examiner should observe the 
condition of the articles and their position, whether torn or soiled, 
displaced or reversed. If any irregularity is observed, he must deter- 
mine, if possible, what significance may be attached thereto. For 
example, singeing about a recent small bullet-hole, with the powder 
markings pointing upward, would indicate that the powder used was 
black and not smokeless, that the weapon was discharged at close 
range, and that the trigger was held in the opposite direction, — i.e., 
down. 1 (Plate VI, p. 449.) Again, seminal stains with marked dis- 
arrangement or tearing of the clothing of a female would strongly 
suggest — at least an attempt to commit — rape. The clothing in 
all such cases should, therefore, be preserved. Before securely 
wrapping and labelling, such perishable articles as one has decided 
to preserve should be disinfected and gum camphor or tar cam- 
phor added, in order to prevent their destruction by moths, as it 
is disappointing at or just before the trial to find the material so badly 
moth-eaten as to be useless for demonstrative purposes. Spots to be 
remembered, such as those made by blood or seminal stains, should 
be designated with thread or ink and a careful note made as to their 
exact location. In handing over to the proper legal officers articles for 
future use, it is well to place upon them in the presence of a reliable 
witness some mark of identification and to get a receipt for every article 
so delivered. The desire of the police to be on friendly terms with the 
reporters often renders the proper study of the surroundings impossible 
or misleading. In one of my cases — a brutal murder by violence — the 
scene had been visited by scores of persons and the body removed to an 
undertaker's before the writer was summoned to perform the autopsy. 
The importance of ascertaining the nature of the substance upon which 
the body rested when found was shown in another postmortem by my 
finding in the rectum of a four-year-old boy " needles" from a Christ- 
mas-tree and a similar " needle" upon the hat of the murderer and 
sodomist many blocks from the place where the crime was committed. 
That the place where an unidentified body is found should be care- 
fully stated is shown by one of my cases. A colored woman confessed 
the placing of the corpse of a new-born male bastard wrapped in a 

1 Brinton, International Clinics, October, 1902. 



6 4 POST-MORTEM EXAMINATIONS 

shawl in an ash-barrel on the corner of A Street, Philadelphia, 

Pennsylvania, in which State the concealment of the death of an 
illegitimate child is a penal offence. The body identified at the post- 
mortem was that of a new-born colored babe wrapped in a shawl, but 

found. in an ash-barrel situated at the corner of B Street, some 

two blocks away. On the plea of the lawyer for the defence that there 

was no corpus delicti, as the body found at B Street was not 

shown definitely to be the body left at A Street, the Judge decided 

that the trial should not proceed and ordered the jury to acquit. This 
was at once done, and, though new evidence might later be secured, 
it could not be used, as the woman could not have her life put in 
jeopardy a second time, though, as in the Mollineux trial, a man 
might once be condemned but on a new trial be acquitted. 

Sex. — The sex is easily determined, except in hermaphrodites, 
where it is sometimes necessary to complete the autopsy and even 
then wait for microscopic sections before deciding as to whether or not 
the question can be definitely settled. An interesting legal question is 
whether an hermaphrodite should be allowed to choose to which sex 
he or she should belong or whether this should be settled by law. 

Race. — As the world becomes more cosmopolitan the racial ques- 
tion must receive more and more attention. It is of especial impor- 
tance to designate mixed races ; thus, in a colored person it is well to 
estimate as closely as practicable the amount of negro blood in the 
body under examination, as mulatto, quadroon, or octoroon. 

Age. — The apparent age should then be carefully considered. By 
apparent age is meant the age of the body as it appears to the judgment 
of the observer at the time of making the postmortem. A person may 
look older or younger than his or her real age, disease, mental depres- 
sion, or dissipation often making the body seem many years older 
than it really is. Per contra, the signs of suffering may pass away, 
the features becoming relaxed and presenting a better appearance 
than they had done for many months before death. If the years cannot 
be estimated with any certainty, one may be able at least to designate 
the time of life as represented by the seven ages of Shakespeare. 

Height. — The height is determined by measuring in a straight 
line from the vertex of the head to the centre of the external arch of 
the instep, the foot being flexed at a right angle to its plane of sup- 
port. If a scale is not marked on the table and no other means of 
measuring is at hand, a piece of inelastic string or tape may be 



EXAMINATION OF THE EXTERIOR OF THE BODY 65 

employed for this purpose and measured later. The writer suggests 
the use of a measuring apparatus modelled on the style of a shoe- 
measure. A simple form can readily be made by taking two one-foot 
rulers, or other sticks of about the same size, and attaching, one inch 
from one end, a seventy-eight inch tape measure, which is made to 
run through a transverse slit one inch from the top of the other ruler. 
If a tape measure of this length is not at hand, forty-two inches of 
inelastic tape may be sewed together and this attached to a measure 
of ordinary length. The first ruler is held close to the foot, which is 
placed in a vertical position, and the other stick is held parallel to the 
first stick by an assistant standing at the head of the corpse, and the 
tape is drawn until it is taut. When not in use the tape measure is 
wound around the sticks. Next measure the circumference of the 
head and shoulders. Should there be shortening of a limb, or atrophy, 
as in fracture and in infantile paralysis, full measurements of both 
limbs are to be made. 

Certain abnormalities of stature are occasionally seen, such as: 

(1) Dwarfism, a condition which may be congenital or acquired. If 
acquired it may be either cretinoid or rhachitic, and is often associated 
with sterility, impotence, bone deformities, or atrophy of the thyroid. 

(2) Giantism appears in two types, infantile and acromegalic, which 
are intimately related. From the literature on this subject, it would 
seem that acromegaly frequently follows giant growth or even the 
period of excessive growth. This condition is often accompanied 
by an abnormal development of the genitalia and changes in the vas- 
cular glands, especially the pituitary and the thyroid. (See also 

P- 2 57-) 

If only part of a body is present, as in the case of Wakefield Gaines, 

where the trunk alone was found, the length may be approximated 
from various data. If the head and upper extremities remain, twice 
the length of the arm from the midsternal line to the tip of the middle 
finger, measured along the flexor surface with the arm in abduction, 
or the distance between the tips of the middle fingers along the flexor 
surface, with the arms extended at right angles to the main axis, will 
about equal the height of the individual. If but one extremity is 
present, twice the length measured from the glenoid cavity plus one- 
half the distance between the glenoids measured between perpendicular 
lines, or nineteen times the length of the middle finger, equals the 
approximate height. Other means of computing the height are: (1) 

5 



66 



POST-MORTEM EXAMINATIONS 



The distance from the tip of the olecranon to the tip of the middle 
finger is five-nineteenths of the height. (2) The upper border of the 
symphysis pubis in an adult is the midpoint of the adult's height, but 
this is not trustworthy in women or persons with deformities. (3) 
From the head of the femur to the plantar surface of the heel is one- 
half the height, while the length of the femur is one-quarter the 
height. (4) Orfila has shown, however, that from one of the long 
bones alone the exact determination of the length of the body is im- 
possible. Manouvrier in cases of extremely short or long bones mul- 
tiplies by coefficients to secure the height, as follows : 1 



MEN. 



Femur. 


Tibia. 


Fibula. 


Humerus. 


Radius. 


Ulna. 


Less than 


less than 


less than 


less than 


less than 


less than 


392 mm. 


319 


318 


295 


213 


227 






Coefficient. 






X3.92 


x 4.80 


x 4.82 


X5-25 


x 7. II 


x6.66 


More than 


more than 


more than 


more than 


more than 


more than 


519 mm. 


420 


413 


368 


273 


293 






Coefficient. 






X3-53 


X4.32 


x 4.37 | x 4.93 


x 6.70 


x 6.26 



WOMEN. 



Less than 


less than 


less than 


less than 


less than 


less than 


363 mm. 


284 


283 


263 


193 


203 






Coefficient. 






X3.87 


X4.85 


X4.88 


X5.41 


X7.44 


x 7.00 


More than 


more than 


more than 


more than 


more than 


more than 


478 mm. 


388 


376 


344 


250 


264 






Coefficient. 






x 3 .68 


X4.42 


X4.52 X4.98 


x 7.00 


x 6.49 



( 5 ) The length of the skeleton from the vertex to the calcaneum plus 
from four to six centimetres about equals the height of the individual, 



1 Rollet has prepared similar tables, which will be found in Vibert's work, 
6th ed., pp. 561, 562. 



EXAMINATION OF THE EXTERIOR OF THE BODY 67 

these figures being added to compensate for the loss of the interartic- 
ular cartilages, the intervertebral disks, and the coverings of the head 
and heel. 

In many cases where homicide has been committed and the mur- 
derer has attempted to destroy the evidence of his guilt, or in de- 
structive accidents, the corpus delicti has been proved by the finding 
of a part or member of the body or a portion of the clothing, as a 
piece of charred bone, a tooth, — as in the Parkman case, 1 — a ring, or a 
button. On the other hand, instances are on record where deluded 
individuals made confessions of murder which were proved to have 
been unfounded by the subsequent appearance in life of the persons 
said to have been killed. So important is this point that time and time 
again juries have failed to convict where the moral evidence was well- 
nigh conclusive. It is only upon irrefutable evidence that the funda- 
mental principle concerning the corpus delicti is disregarded. 

Where only a part of the body is available for examination, con- 
siderable difficulty is apt to arise as to the best method of procedure. 
The examiner will then need to possess a wide knowledge of compara- 
tive and pathologic anatomy and to exercise great ingenuity in order 
satisfactorily to demonstrate the identity of the parts submitted. 
Should the only proof of the corpus delicti be a skeleton or a portion 
of one, the expert may be asked to determine the age, race, and sex 
of the person, and the probable date at which death took place, — 
whether the bones are old or recent. With limitations, the age would 
be known by the condition of the epiphyses, whether united or not ; by 
the cranial sutures, whether closed or not; and by the state of den- 
tition. Race would be indicated by the different racial characteristics 
and peculiarities: thus, the negro by his splay-foot, projecting heel, 
and prognathous jaw; the Caucasian by his higher forehead, wider 
facial angle, and larger cranial capacity. Evidence of this character 
is not by any means conclusive. The determining of sex, after the 
age of puberty, presents less difficulty. In man the size of the cranium 
is greater and all the bony points are heavier and more prominent, the 
angle of the neck of the femur with the shaft is greater, and the lower 
jaw is heavier; in woman the bones are lighter and more compressed, 
the patella is smaller, and the articular surface of the femur and 
tibia is narrower. The characteristic differences are, however, found 

1 Report of Trial of Prof. Webster, Boston, 1850, p. 50. 



68 POST-MORTEM EXAMINATIONS 

in the broad female pelvis, the diameters of which are all greater with 
the exception of the vertical ; the sacrum and coccyx are more curved, 
and there is greater spread of the arches of the pubes. 

The probable age of the bones would be indicated by their condi- 
tion and appearance. The presence of the marrow and the periosteum 
is the most conclusive evidence of a recent state. The soft parts are 
usually destroyed within two years. Under ordinary conditions the 
body skeletonizes in about ten years, although this period is subject 
to wide variations, depending upon the cause of death, the chemic 
properties of the soil in which the body was found, and whether or 
not preservatives were used. 

Weight and Nutrition. — Next weigh the body, if this has not 
already been done, or at least estimate its weight. Particularly observe 
the state of somatic nutrition. If emaciation be present, note whether 
it is due to a deficiency of fat (panniculus adiposus), to muscular 
atrophy, or to a combination of both. This can readily be determined 
by picking up a fold of skin over a muscle and rolling it between the 
thumb and fingers. One may study upon his own person the differ- 
ences existing in various parts of the body, noting especially the 
varying thickness of the integument in the front, the back, and the 
sides of the neck. The greatest emaciation occurs in phthisis, atrophic 
cirrhosis, muscular atrophy, and cancer of the upper digestive tract. 
The fat may be the corpulency of a high liver, of a gouty person, or of 
one suffering from cardiac affections. Women have a tendency to 
become obese as they reach the change of life. 

An excessive deposit of fat may be due to adiposis dolorosa, in 
which condition there is a great increase of adipose tissue, not uni- 
formly distributed, but occurring in lumps, the forearms, hands, legs, 
and feet often being without any or with but slight deposits of fat. In 
some cases there is also a thickening of the synovial membranes, with 
a tendency towards the formation of joint fungi and rice bodies, — 
probably a fatty infiltration. In one case reported by Dercum, in a 
man four feet eight inches in height, the patient weighed' two hundred 
and six pounds. 

Skin. — Some of the bodies coming to autopsy are so filthy that 
no true estimate of the condition of the skin can be made until they 
have been cleansed. In vagabondism and alcoholism a distinct cuta- 
neous discoloration often occurs due to the habits of the subject. Lice 
upon the body or head may be quickly and effectually disposed of by 



EXAMINATION OF THE EXTERIOR OF THE BODY 



6 9 



saturating a towel with chloroform or kerosene and placing it upon 
the part affected for a few moments preparatory to its opening. For- 
malin may be used for this purpose if it can be applied several hours 
previous to the postmortem, so as to allow time for the evaporation of 
its fumes, which are so irritating as to forbid its application when the 
autopsy is to be made immediately afterwards. 

The color of the skin is of great importance. It varies much in 
health and still more in disease and after the appearance of hypostatic 
congestion. Native Africans vary from yellowish brown to jet black. 
The children of negroes are usually creamy yellow when born, while 
it has been stated that the offspring of a mulatto mother and a full- 
blooded negro father is very dark at birth. The integument of a 
cadaver rarely possesses the rosy hue of health, but is rather of a 
grayish white, which shade is most conspicuous in cases of fatal 
poisoning by chlorate of potassium. The skin on those parts which 
have been exposed to the sun is generally more or less tanned, while in 
jaundice the color varies from the faintest tinge of yellow to a dark 
yellowish brown. Yellow color is also noted in chlorosis (yellowish 
green) and in pernicious anaemia (lemon-yellow). In the latter 
brown spots are also frequently found, usually situated on the abdomen, 
groin, buttocks, and thighs. Pallor is due to a primary anaemia or loss 
of blood, and is often so marked as to suggest the possibility of internal 
hemorrhage, as from the rupture of an aneurism or of the sac in extra- 
uterine pregnancy. The cachexias of cancer, argyria, etc., are at times 
peculiarly conspicuous in the dead body. The patches of bronzed skin, 
alternating with unaffected areas, seen in Addison's disease, may be 
scattered over the entire body, but are especially well marked on the 
abdomen; they are also sometimes found upon the mucous membrane 
of the mouth. This bronzing may occur when the suprarenal bodies 
are still apparently normal. Brown lines and a brown areola around 
the navel are observed during pregnancy; patches on the face may 
also appear. A white skin is found in albinism, vitiligo (where it 
occurs in patches), and in leprosy. Moles, tattoo marks, and certain 
cutaneous diseases, as leucoderma, cause characteristic discolorations of 
the integument. Redness of the skin is important. It may be simply 
a discoloration from some red clothing, or an erythematous inflamma- 
tion, which, as a rule, however, disappears post mortem. In cases of 
asystolic cardiac disease a bluish-red cyanosis is often seen, but general 
reddening of the body is more likely to be a post-mortem lividity, 



;o 



POST-MORTEM EXAMINATIONS 



though it may be due to congenital or other forms of heart disease. 

The breasts should be carefully examined in all cases, and the shape 
and size of the gland noted. The presence of any fluid in the breast 
should be detected by making pressure upon the gland, and its char- 
acter described after being studied under the microscope, especially in 
cases of abortion. Certain inflammatory conditions are found in the 
breast, the infection usually entering through a wound, abrasion, or 
fissure of the nipple. The infection may remain localized to the nipple, 
causing a simple ulcer or abscess, or produce a general affection. The 
abscess may be due to infection by the organisms of typhoid fever, 
tuberculosis, etc., the latter being miliary or diffuse. Several cases 
have been reported where the nipple became infected accidentally from 
vaccination. Atrophy of the gland is observed in the old, and hyper- 
trophy is sometimes seen in the young. Supernumerary breasts and 
nipples occur; a well-formed breast with a nipple has been reported 
in the axilla and one in the groin. Tumors are very common in the 
female breast, but rare in the male. They are at times discovered by 
palpation, at other times are visible to the naked eye, and may, as in 
cancer, become great ulcerous patches. The most common tumor is 
cancer, which is most often found in the upper outer quadrant of the 
gland. Paget's disease is an inflammatory dermatitis of the areola 
and nipple, and is often a precancerous lesion. The glands of the neck, 
axilla, and supraclavicular region should be palpated and will often 
be found enlarged. Adenocarcinoma, adenocystoma (also known as 
chronic cystic mastitis), adenosarcoma, adenofibroma,, adenocystic 
sarcoma, chondroma, myoma, myxoma, round- or spindle-celled 
sarcoma, adenoma, lipoma, and fibroma have been found in these 
glands. 

In the general survey of the body, relaxed abdominal walls, with 
the striae (linese albicantes) of the multipara or of the patient who has 
had ascites, are to be described, also the enlargement of the superficial 
veins so often found in chronic heart, lung, and liver disease (espe- 
cially in atrophic cirrhosis), tumors, aneurisms, thromboses of portal 
vein, etc. Atheroma of the temporal arteries may be present, causing 
them to stand out like rods. Gastroptosis and enteroptosis are often dis- 
cernible on inspection. (Edema, general or local, is investigated, espe- 
cially as to its extent and the character of the pitting on pressure. 

Now examine the skin for any abnormal marks, such as eruptions, 
scars, wounds, bruises, blood, dirt, discolorations, etc. The amount 



EXAMINATION OF THE EXTERIOR OF THE BODY y 1 

of cutaneous injury does not always afford a true index of the lesions 
found internally. Thus, it is possible for a wagon or even a street-car 
to pass over a child without leaving any external trace other than a 
brush-burn, though upon opening the body the pelvis may be found 
crushed and the abdomen full of blood. As a rule, all eruptions and 
inflammations of the integument are pale and have a tendency to dis- 
appear at the postmortem. This is especially true of those on the 
mucous membranes and after the administration of certain drugs, as 
the purpuric rash from the use of quinine. The erythema produced 
by potassium iodid and mercury entirely disappears, though mercury 
may cause papules, vesicles, pustules, or even an exfoliative dermatitis, 
— lesions which remain and can be studied. 

Even an extreme eruption of measles may disappear post mortem, 
and in these cases, if a study of the lesion be desired, it is a wise pre- 
caution before death to mark the place to be examined with a der- 
mographic or anilin pencil or by the use of silver nitrate. In other 
diseases, as chicken-pox, smallpox, etc., the eruption is permanent. 
Chicken-pox, which may be coincident with smallpox, starts with 
vesicles that come out in crops. The eruption is very superficial, rarely 
umbilicated, and has no areola; it may become pustular, and often 
leaves scars. The lesions are most profuse on the trunk, especially the 
back, and as they dry up leave a black crust. Smallpox, on the con- 
trary, begins as maculo-papules, which pass into vesicles, and lastly 
form pustules, all three conditions being often found at the same time 
in different parts of the body. The papules are deeply seated, indu- 
rated, and feel like shot when rolled between the fingers. The vesicles 
are multilocular and difficult to rupture. Smallpox may be associated 
with a pre-eruptive general purpuric rash. Malaria may be accom- 
panied by urticaria, angioneurotic oedema, erythema multiforme, bullae, 
herpes zoster, eczematoid eruption, and gangrene. 

The number and variety of skin eruptions are legion, but eczema, 
acne, syphilis, alopecia, and psoriasis form 75 per cent, of all cases 
met with. In skin diseases certain definite lesions are found. Macules 
occur in syphilis, erythema multiforme, pityriasis rosea, pediculosis, 
measles, purpura, scurvy, rheumatism, peliosis rheumatica, extreme 
anaemia, typhus fever, and poisoning from snakes, mercury, antipyrin, 
etc. Brown macules include freckles, chloasma, moles, and naevus 
pigmentosus. White and pale yellow macules are seen in vitiligo, lep- 
rosy, morphcea, and facial hemiatrophy. Vesicles are found in herpes, 



72 



POST-MORTEM EXAMINATIONS 



especially around the eyes and the lips, in dermatitis venenata (ivy or 
oak poisoning), impetigo, eczema, miliaria, and scabies. Blebs are 
seen principally in impetigo, where they are flat and umbilicated ; pem- 
phigus, having no areola ; dermatitis herpetiformis, and as clusters in 
syphilis. Pustules occur in eczema, acne, dermatitis herpetiformis, 
impetigo, varicella, ecthyma, smallpox, syphilis, scabies, and furuncu- 
losis. Papules occur in lichen, scrofulosis, prurigo, erythema multi- 
forme; after the use of bromids, iodids, copaiba, cubebs, and tar; in 
eczema, miliaria, acne, scabies, syphilis, smallpox, measles, lichen 
ruber and planus. Ulcers are associated with syphilis, epithelioma, 
lupus, trauma, locomotor ataxia, bed-sores, etc. Large tubercles on 
the skin are associated with erythema nodosum, erythema multiforme, 
lupus vulgaris, syphilis, tinea sycosis, and leprosy. Crusting is found 
with eczema, seborrhcea, psoriasis, ichthyosis (where there is abnormal 
cornification of the sweat glands and hair follicles), syphilis, pityriasis, 
ring-worm, and scarlet fever. 

Besides these common forms there are other interesting lesions 
which should be looked for, as chimney-sweepers' dermatitis, Rontgen 
ray dermatitis and burns, ulcerating lesions of syphilis, actinomycosis 
and anthrax, scurvy and purpura; circumscribed keratosis, as in 
cutaneous horns; arsenical poisoning; seborrhcea, especially the senile 
variety of the French authors, which occurs in pinhead to dime-sized 
spots, more or less elevated, friable and slightly greasy or dry and hard, 
with yellow, brown, or black crusts which are firmly adherent to the 
skin and found especially on the exposed parts of the body. 1 These 
lesions, as well as nsevi, may become epitheliomatous later on. In 
blastomycosis (oidiomycosis, Gilchrist's disease) of the skin the lesions 
are principally found on the hands, arms, face, and lower extremi- 
ties. Internal lesions may occur therefrom secondarily. Tuberculosis 
of the skin is rare in this country. It appears in several forms, lupus 
vulgaris being the most common. The anatomic wart has been con- 
sidered in Chapter IV. 

Dermatomyositis sometimes occurs and may be described with the 
skin lesions. It consists of a swelling of the muscles, associated with 
an erythematous and pustular eruption and emaciation. The cedema- 
tous swelling may be followed by desquamation. 

Certain occupations induce special affections, as the inflammations 

1 Hartzell, Jr. of Cutaneous Dis., September, 1903. 






EXAMINATION OF THE EXTERIOR OF THE BODY 



73 



peculiar to those working in tar and paraffin, the necrosis of the jaw 
in match-makers, etc. Atrophy of the skin may follow injury to or 
inflammation of nerve-filaments. It at times accompanies pernicious 
anaemia. Induration of skin is seen in scleroderma, myxcedema, con- 
genital ichthyosis, and keloid. It accompanies oedema of subcutaneous 
tissues and scurvy, especially in the legs. Trophic affections of the 
skin, especially of the extremities, may be found in puerperal fever, 
gangrenous lymphangitis, diabetes, uraemia, ergotism, locomotor 
ataxia, etc., and is usually present in cases of angioneurotic oedema. 

The yellowish deposits of xanthoma are among the striking and 
peculiar affections of the skin. They are found especially on the 
eyes and in the palmar creases. As one variety may occur associated 
with diabetes, this disease should be always borne in mind. MacFar- 
land considers this condition to arise from some disturbance of the 
connective tissue which causes multiplication of the cells followed by 
fatty infiltration. 

Skin eruptions are frequently found with Bright's disease, (i) 
Those of the early stage are pruritus, urticaria, and eczema. (2) 
Those of the final stage are universal erythema and bullous or des- 
quamative eruptions. (3) Purpura or hemorrhagic eruptions may 
occur at any time during the disease, and affections due to marked 
oedema are also present in certain cases. 

The tumors found in the skin are the wen or steatoma, lipoma, 
verruca or wart, naevus pigmentosus and naevus vasculosus, morphoea 
or keloid, molluscum fibrosum (which may cover the entire body), 
xanthoma, epithelioma (seen usually on the face), angiomata, which 
may undergo malignant change, adenoma, cancer, and sarcoma. Cuta- 
neous horns should not be overlooked. 

An entire chapter might easily be written on the significance and 
value of scars produced in various ways. Those made by the surgeon 
are often from their location self-explanatory, as the cicatrix after 
tracheotomy, trephining of the skull, or the mastoid operation. 1 It 
would, however, certainly facilitate matters, in this age of numerous 
hospitals and frequent operations, if the absence of organs removed 

1 The writer once desired to secure for a friend some fresh testicular tissue, and 
hurried to a recent suicide for the purpose of obtaining the testes. Finding scars 
on the scrotum, but no testicles, it was learned on investigation that these organs 
had been removed several years previously, and the young man, being in love, had 
hung himself because he felt that, being thus mutilated, he ought not to marry. 



74 



POST-MORTEM EXAMINATIONS 



by operation were indicated by some method which would be gen- 
erally understood. Thus, the first letter of the Latin name of the part 
excised followed by the sign minus might be tattooed on the skin 
near the initial incision : e.g., A — would show that the appendix had 
been removed, R — that nephrectomy had been performed, etc. The 
presence of scars may lead the obducent to think of herpes zoster, 
cupping, smallpox, chicken-pox, various skin diseases, as acne and 
syphilis, explosions, setons, certain occupations, previous application 
of croton oil, leeches, etc. 

Scars made by the hypodermic needle in persons addicted to the 
use of morphine are usually found on the arms and thighs, — i.e., in 
those situations which are hidden by the clothes and yet are easily 
accessible to the individual. Small, multiple abscesses are often to 
be found in these cases. Hypodermic injections by physicians shortly 
before death are usually made over the deltoid muscles or the breast, 
this region being selected owing to the quickness with which the drug 
is here absorbed into the general circulation. The puncture may be 
surrounded by an elevated white or reddish area similar to that pro- 
duced by the application of cups. Recent saline injections (dermo- 
clysis) also leave marks upon the skin. Exploratory punctures made 
by physicians at times end disastrously, as three of the several cases 
seen by me demonstrated. In one the trocar had penetrated the lung 
and given rise to abscesses which resulted in death. In another case 
the exploratory needle used in searching for right-sided pleural fluid 
penetrated the liver and caused fatal hemorrhage. In the third case, 
one of suspected pericarditis, the needle had passed through the lung 
and penetrated the right ventricle. There was no pericarditis present 
at autopsy, but a markedly hypertrophied heart. 

Much discussion has arisen in regard to the means at our command 
for distinguishing a wound inflicted before and one made after death, 
and as to which is the fatal injury where there is more than one 
wound. On these and similar questions I have heard experts testify 
in court in a manner utterly unsupported by the facts of the case, and 
in a manner they would not do if talking before their county medical 
society. Great caution should, therefore, be used in the expression 
of dogmatic statements concerning such findings. Any blood found 
on the body should be accounted for and all bruises, injuries, etc., accu- 
rately located and described so as to be intelligible to the lay mind. 
In cases of death by electricity the points of entrance and exit of the 



EXAMINATION OF THE EXTERIOR OF THE BODY 75 

current ought to be carefully sought for, and the shoes should be 
examined for the burns in the leather which are usually seen near the 
nails in the heels. In one of my eight cases of death from electricity 
a man carrying an umbrella with a steel handle, while looking into a 
shop, made connection with the arc light above the window and died 
instantly from the current thus transmitted. 

Parchment-like spots are often seen on the body where the epi- 
dermis has been robbed of its protecting epithelium. Such areas are 
due to the drying of the part, and if produced during life there will 
usually be some ecchymotic spots around them. When seen about the 
mouth, they may have been caused by such agents as strong acids 
(especially carbolic) and alkalies. 

The drawn-up and wrinkled appearance of the skin known as 
" goose-flesh," or cutis anserina, — due to the post-mortem contraction 
of the involuntary muscles of the skin, — excoriation of fingers, mud, 
sand, water plants, etc., under the nails and in the hands, mouth, 
nostrils, and ears are especially conspicuous after drowning. 

Note the presence of bed-sores and blisters, remembering that 
scalds found on dead bodies are sometimes due to carelessness in the 
use of hot-water bags or bottles during the final illness. 

The region of the neck should be carefully inspected for finger 
markings, scratches, rope markings, etc. The neck should be rotated 
to ascertain if a fracture or a dislocation exists. Tumors are not 
infrequent in the neck. Madelung 1 describes a special multiple form of 
lipoma in this region. In infants a sucking gland is found in each 
cheek. Cysts may be due to occlusion of the salivary glands. 

Enlarged glands can be seen or palpated ; they become conspicuous 
in cases of tuberculosis, leukaemia, cancer, etc. An enlarged thyroid 
should be measured and examined. A slight enlargement of this 
gland is often seen in pregnant women and women at term, the hyper- 
trophy disappearing during the puerperium. Percussion may reveal 
a pleurisy, extensive infiltration of a new growth in the mediastinum, 
an ileocecal abscess, ascites, enlarged organs, as a spleen or liver, etc. 
The presence of gall-stones or of an hydatid cyst may at times be 
elicited by manipulation. 

Ascites can sometimes be detected by an elevation of the umbilicus, 
the finger being used to depress the part. Echinococcus cysts, encap- 

1 Von Langenbeck's Arch., 1888, xxxvii. 



7 6 



POST-MORTEM EXAMINATIONS 



sulated peritonitic exudates, ovarian cysts, primary carcinoma, and 
allantoic cysts of the urachus may all be found at the navel. 

Deformities. — The body should now be carefully examined from 
head to foot and from left to right, and any variations from the normal, 
either bony or muscular, minutely described. Deformities may be 
congenital or acquired, single or multiple, symmetrical or asymmet- 
rical. Babes 1 believes that there is a special centre, situated in the 
anterior base of the skull in the upper part of the face, which presides 
over the development of the limbs, and that disease of this region 
produces a tendency to the formation of symmetrical deformities. 

Congenital Deformities. — These may be due to embryologic de- 
fects or to traumatic or pathologic intra-uterine causes. Injury during 
delivery is responsible for quite a number of these cases, Allis recently 
advocating that congenital dislocations of the hip are produced at the 
time of birth. Those interested in the pathology of congenital dis- 
location of the hip will find an excellent illustrated article on this 
subject by Carl Ludloff in Klinisches Jahrbuch, 1902, vol. x, no. 1. 

According to Hirst and Piersol, the most common monsters are : 

I. Single Monsters : ( 1 ) Autositic Monsters. — Ectromelus, 
aborted or imperfectly formed limbs; symelus, a union of two limbs 
and imperfectly developed pelvis; celosomia, body cleft with some 
eventration, and with anomalies of limbs and genito-urinary apparatus ; 
exencephalus, a foetus with malformed brain, part at least without 
cranium; pseud 'encephalus, bones of vault absent or very rudimentary 
and brain rudimentary ; mouth a mere opening ; anencephalus, a foetus 
without a cranium or brain; cyclocephalus, 3. union of the eyes, gen- 
erally with an absence of the nose; otocephalus, lower jaw wanting; 
ears approach each other. (2) Omphalosite Monsters. — Paracepha- 
luSj imperfect extremities; imperfect head and face; lungs absent or 
rudimentary; heart often absent; one member of a unioval twin, sex 
feminine; acephalus, complete absence of head and upper extremities, 
rudimentary or absent heart, lungs, etc. ; asomata, trunkless head, 
which is not well formed; no cord; anideus, shapeless mass covered 
with skin. 

II. Double Monsters : Double Autositic Monsters. — (1) Terata 
Katadidyma: Metapagus, two foetuses united by their cephalic ex- 
tremities ; pygopagus, two foetuses united in the region of the buttock ; 

1 Berliner klin. Wchnschr., 1904, vol. xli, no. 18. 



EXAMINATION OF THE EXTERIOR OF THE BODY 



77 



ischiopagus, two foetuses united by the pelves, coccyges, and sacra, 
with a common umbilicus ; dicephalus, with two distinct heads, usually 
separate necks; diprosopus, having a double face, body single. (2) 
Terata Anadidyma : Dipygus, double pelvis, lower extremities, and 
genitalia; syncephalus, division up to navel and imperfectly formed 
up to head; craniopagus, bodies joined at homologous parts of the 
cranium. Laloo was an illustration of a Dipygus parasiticus. (3) 
Terata Anakatadidyma : Prosopothoracopagus , twins united by the tho- 
rax, abdomen, and face; omphalopagus, united at the umbilicus; 
rhackipagus, united at the vertebral column. The Siamese Twins were 
examples of monsters of the xiphopagus variety, where the individuals 
are united from the umbilicus to the xiphoid cartilage. 

III. Triple Monsters. In composite monsters there is a com- 
plete or partial union of two or more foetuses. 

IV. Double Parasites : Heterotyphus, a parasitic foetus hanging 
from the anterior abdominal wall of the principal; heteralius, a para- 
site inserted at a distance from the umbilicus of its host and having no 
direct connection with the batter's cord; polygnathus, ill-developed 
fetal parts joined to jaw of autosite; polymelus, duplication of lower 
extremities; endocyma, the greater part of the parasite within the 
body of the autosite. 

Spina bifida is a defect in the union of the laminae of one or more 
vertebrae, with more or less malformation of the spinal cord or its 
membranes. While spina bifida usually shows itself posteriorly, it 
may do so entirely alone or in combination with an anterior opening, 
and, at times, with increase of size due to the presence of a lipomatcus 
mass. Encephalocele is a hernia of the brain, and meningocele a her- 
nial protrusion of the meninges. 

Various other defects and lesions may be found : as, e.g., complete 
or partial absence of the nose; imperforate ala nasi ; deviation of the 
septum ; various abnormal shapes, as saddle-back in hereditary syphilis. 
Palate, cleft. Cheeks, fissures and fistulae. Ears, absence of the helix ; 
haematoma. Mouth, imperforate, abnormally large (macrostoma), 
abnormally small (microstoma). Atresia oris, besides being con- 
genital, may be due to cicatrization from burns. Tongue, absent; 
cleft; atrophied (microglossia); hypertrophied (macroglossia) ; or it 
may be adherent to the palate. The fraenum may be too short or too 
long. The hairy tongue is due to cornification of its mucous mem- 
brane. Alveolar process, absent; cleft; atrophied; hypertrophied. 



78 



POST-MORTEM EXAMINATIONS 



Lips, cleft (harelip); cysts. Neck, tracheal fistula; cysts on visceral 
clefts. Fingers and toes, absent; atrophied; hypertrophied ; super- 
numerary ; webbed ; or clubbed. Sternum, absent, malformed, or fis- 
sured. Ribs , cervical ribs and various defects in their development. 
Umbilicus, skin insertion of the cord; abnormalities of the vessels; 
hernia. Urachus, persists and remains patent. Bladder, extroversion. 
Penis, the glans may be atrophied, hypertrophied, or phimosis or 
atresia may be present; often imperfectly formed in cretins. The 
entire penis may be absent, but this condition may be due to amputa- 
tion, traumatic or pathologic, in which case the scar will be present. 
Scars on glans or prepuce are usually syphilitic. An elongated or 
fissured penis is often associated with calculi. Epispadias or hypo- 
spadias may exist. The penis may be found erected after death by 
hanging, injury to spinal cord, or drowning. It may be affected with 
gangrene or cancer, and the arteries may show arteriosclerosis, the 
latter condition being rare. Testicles, one or both may be absent from 
the scrotum or from the body altogether; they may not have de- 
scended, or may be found in some abnormal position not in their 
line of descension. There may also be found atrophy; hypoplasia, 
a condition often present in imbeciles; hypertrophy, congenital or 
acquired, or compensatory in one testis, as after the removal or de- 
struction of its fellow; duplication or malformation. Abdominal, 
crural, cruroscrotal, or ilio-abdominal ectopia may occur. These organs 
are usually retracted in cases of drowning. Scrotum, absent, atro- 
phied, or hypertrophied; gangrenous lymphangitis is seen sometimes 
in children. The hypertrophied condition may be acquired, as in 
elephantiasis. Filaricc are possibly introduced by the bite of a 
mosquito, the Culex pipiens. Other conditions may be cleft scrotum, 
hydrocele, hematocele, varicocele, and hernia. It may be contracted in 
cases of drowning. Vulva, absent; imperforate; atrophied; hypertro- 
phied. The Bartholinian glands may become enlarged, forming reten- 
tion cysts ; abscesses ; tumors, as fibroma, chondroma, lipoma, sarcoma, 
carcinoma, and myoma. Aphthae occur as white spots on the mucous 
membrane; elephantiasis; herpes progenitalis ; diphtheritic ulcers; 
acne; eczema, especially on the skin of the labia, the vulva, or the 
nymphae, sometimes giving rise to atresia or stenosis ; lupus ; syphilis, 
as the chancre, mucous patch, or gumma; gonorrhoea, as a purulent 
vulvitis; chancroid; and venereal warts are found. Injuries are 
common after parturition and rape. Hematoma, rupture of varicose 



EXAMINATION OF THE EXTERIOR OF THE BODY yg 

veins, lacerations, cedema, etc., are seen. Clitoris, absent; atrophied; 
hypertrophied, in which case it may simulate hermaphrodism ; car- 
cinoma. Anus, absent or imperforate, or may end in a blind sac. 
Fissures, indurated and irregular. Small polypoid growths may fringe 
the borders. All lesions around the anus are at times altered by the 
distortion of the part with the cotton introduced by those who have 
had the body in charge. Rectum, prolapsed. This condition is com- 
mon in children. The rectum may be imperforate or contain congeni- 
tal polypi, internal or external hemorrhoids, carcinoma, sarcoma, and 
various other tumors. Fistulse, internal or external, complete or incom- 
plete, may follow abscesses. Hymen, absent; imperforate; fimbri- 
ated. Its absence may be due to traumatic causes or rupture during 
menstruation. An ovary may lie in the canal of Nuck. Urethra, 
absent or occluded ; atresia or partial phimosis. It may have abnormal 
openings, as on the penis, scrotum, perineum, clitoris, or rectum, in 
the last case forming a urethrorectal fistula. It may be cleft, present- 
ing a condition of epispadias or hypospadias. It may be inflamed 
(urethritis), with or without Gonococci, and showing a bloody, muco- 
purulent, purulent, or altered spermatic discharge. Chronic urethritis 
occurs with thickening of the tube. It may be torn by the passage of a 
stone or foreign body. Stricture may occur, in the male, as a rule, 
four to six inches from the meatus. Tuberculosis is extremely rare. 
Tumors, as fibroma, angioma, sarcoma, epithelioma, are seen. Con- 
dyloma or caruncle may be found. 

Congenital hypertrophies may be confined to the big toe, and are, 
as a rule, associated with disturbances of the genitalia or a persisting 
thymus gland. In rare instances the enlargement is general, as in 
giantism, a condition not uncommonly acquired, when it is apt to be 
irregular and partial, affecting usually the bones of the face and skull 
(leontiasis ossea). Although appearing soon after birth, it more 
often arises at puberty and is due to an abnormal proliferation of the 
cartilages in the process of endochondral ossification. Acromegaly, a 
condition due to some lesion of the pituitary body, is often a cause of 
giant growth, the enlargement affecting the face bones and the distal 
ends of the long bones. Local hypertrophies due to inflammation and 
rhachitis are not at all uncommon. Rokitansky describes deposits of 
phosphates and salts of lime in the cranial and pelvic bones of pregnant 
women; these are the analogues of the "plaques choriales" of sheep, 
which probably contribute to the development of the fetal skeleton. 



80 POST-MORTEM EXAMINATIONS 

The opposite condition, atrophy, is much more common. The 
general congenital form is the microsomic dwarf (normal proportion), 
a rare condition, the stunting more often affecting only one part, and 
being due to ischasmia or inflammation in utero. It may affect a 
limb (agenesis), skull (microcephalus), pelvis, etc. Acquired micro- 
somia (cretinism, etc.) is the result of absence or disease of the thyroid 
gland, which produces an arrest of development in the longitudinal 
growth of the cartilaginous bones and in the lateral growth of the 
membranous bones. Rhachitis and synostoses are other causes of 
stunted development. Partial atrophy, if congenital, is often confined 
to the head, tibia, fibula, or radius, and is, as a rule, associated with 
other deformity. There may be an entire absence of bones or parts, 
as in apodia, or the lack of a clavicle, scapula, or radius. 

Signs of Degeneration. — Closely connected with malformations 
are the signs of degeneration, as misshaped ears and nose, asymmet- 
rical face, deformed fingers, and some anomalies of the penis, vulva, 
and anus, which should be noted for their statistical value. 

Fractures. — Deformities due to fractures are very common. 
Their character depends upon the location, the bones broken, and the 
age of the fracture. A recent fracture will exhibit crepitus, swelling, 
increased mobility, and deformity due to contracture of the muscles; 
this contracture, however, may disappear post mortem. If the fracture 
is old there may be non-union, false union, union with deformity, 
false joint, or a non-absorbed callus. Deformity due to fracture of 
the shaft of a bone can be more easily found by making comparisons 
between the same bones on both sides of the body, as the femora, 
humeri, and tibiae. Likewise comparisons should be made between 
similar joints, especially the shoulder, elbow, hip, knee, and finger 
joints, to determine whether the deformity be a fracture or a dislo- 
cation. Fractures and dislocations of the neck are frequently over- 
looked, owing to lack of careful examination of these parts. 

Dislocations. — Dislocations are also common sources of deform- 
ity. They may be: (i) Congenital, as illustrated in club-foot. (2) 
Traumatic, resulting from direct or indirect violence or muscular 
action. These two forms are the ones commonly met with. (3) Patho- 
logic dislocations, due to degenerative changes in the joint, as occurs in 
tabes and Charcot's joint. Recent dislocations rarely show inflamma- 
tory changes, whereas older ones present evidences that such changes 
have occurred. Contractures are caused by nervous diseases, cicatrices 



EXAMINATION OF THE EXTERIOR OF THE BODY 8l 

with loss of skin and subjacent tissue, burns, and other accidents. These 
contractures are occasionally due to spontaneous dislocations. In old 
traumatic cases ankylosis is sometimes present. Ankylosis also occurs 
in pathologic conditions. 

It may be important to examine the hyoid bone and laryngeal 
cartilages for fracture, dislocation, or laceration. In a case recently 
tried in the New York courts a patient was supposed to have received 
harsh treatment from an attendant in one of the hospitals there. The 
case hinged on determining whether a fracture of the hyoid bone had 
or had not been produced during life. 

Pathologic Deformities. — Such distortions are due to diseases which 
may produce certain changes in the bone structure. The most com- 
mon of these disorders are rickets, tuberculosis, syphilis, osteomalacia, 
acromegaly, and osteitis deformans. Rhachitis is a general cause of 
many varieties of deformity. In this disease the bones lose their 
tenacity and hardness, change in consistency (usually being thickened 
and spongy), and become distorted by the action of the muscles. 
These processes produce certain deformities : ( i ) Of the extremities, 
bow-leg (genu varum or extrorsum), knock-knee (genu valgum). 
(2) Of the sternum and ribs, pigeon-breast (pectus carinatum), 
funnel-breast, Harrison's groove, beaded ribs. (3) Of the cranium, 
the square-box rhachitic skull, in the bones of which may be found 
spots of craniotabes. (4) The subject may be more or less dwarfed. 
These are the most common malformations. 

Tuberculosis is often associated with a long, narrow chest, and is 
a source of common deformities, seen in coxalgia, Pott's disease, knee- 
joint disease (hydrops articuli), and the various grades of spinal 
curvature. Syphilis in its secondary and tertiary periods may produce 
nodes or cause great destruction of bone-tissue. This process is 
present whether the malady be of the inherited or acquired variety. 
Osteomalacia causes bone softening, which may be followed by various 
deformities, especially fracture. This disease usually occurs in women 
after pregnancy. Osteitis deformans also produces changes in bones, 
usually those of the extremities. Certain chronic lung conditions 
result in contraction of one side of the chest and often a corresponding 
scoliosis; emphysema of the lungs is accompanied by a barrel-shaped 
chest; nervous diseases lead to more or less disfigurement of the 
body, as facial paralysis and spastic paraplegia; pernicious anaemia 
may either cause or be associated with spinal deformities; pleurisy 

6 



82 POST-MORTEM EXAMINATIONS 

may give rise to unilateral enlargement of the chest; aneurism may- 
cause protrusion of the sternum. (For a further discussion of the 
changes found in bones and joints, see Chapter XVII.) 

Tumors and other abnormal growths are also a common source of 
marked deformity. While deformities of the bones are the most fre- 
quent and conspicuous, yet there are other acquired deformities which 
are quite important. Congenital fissures of the neck which are tubular 
and go to the thyroid cartilage, and the tuberculous perianal fissures, 
should be followed out by careful dissection to their point of origin. 

Muscular Deformities. — These are most generally due to muscular 
weakness. They may coexist with bone deformities and even cause or 
be caused by them; as deviation of the spine due to bone deformity 
destroys the harmony between the dimensions of the bones and the 
muscles, some muscles becoming elongated and others shortened. 

Acquired Deformities. — Nature itself may produce deformities, as 
those arising from age, habits, and occupations. Notwithstanding 
that persons assume particular positions most constantly in certain 
occupations, they do not often acquire deformities. 

Tophi. — These deposits occur in gouty persons, and are generally 
found in and about joint-cavities, ligaments, tendon-sheaths, aryte- 
noids, epiglottis, vocal cords, skin of the penis, helix of the ear, tarsal 
cartilages, and margins of the eyelids. They contain a urate and a 
biurate, both of which dissolve in either acetic or nitric acid and give 
the murexid test for uric acid. If large and advanced they leave a 
white chalk-line when rubbed. Superficial tophi are movable and 
the skin over them is non-adherent, but as the process advances the 
mass adheres and may finally protrude. They are easily differentiated 
from sebaceous cysts. 

Hernia. — Hernia being of common occurrence and a frequent 
cause of death, the various situations where this defect may occur 
must be thoroughly inspected. The abdomen, inguinal canals, fem- 
oral openings, and umbilical region should be carefully palpated. The 
scrotum should be examined to determine the absence of one or both 
testicles, and when these are not found search for them should be made 
in the canal and elsewhere. 

Eyes. 1 — Inquire whether the eyes and mouth were open or closed 
when death occurred, and whether the expression was peaceful or the 

1 Much interesting material on this subject will be found in Parsons's Pathol- 
ogy of the Eye, vol. i, 1904; vol. ii, 1905. 



EXAMINATION OF THE EXTERIOR OF THE BODY 83 

countenance distorted. While in life expression is manifested princi- 
pally by the eyes and the action of the facial muscles, in death the 
eyes lose their lustre and fail largely to influence the expression. 

Abnormalities. — The eyes should be carefully examined in every 
postmortem, as abnormalities are quite common. The eyelids may 
be wholly or completely absent. They may not be divided, or a fissure 
may exist involving one or both lids. There may be eversion or 
inversion. Ptosis, either acquired or congenital, may be present; if 
acquired, it may be due to specific causes. One or both eyes may have 
been replaced by artificial ones. The eye sometimes appears intact 
where sight had been absent for years before death, in which case 
there is always evidence that blindness existed. Abnormal prominence 
is usually caused by cavernous aneurism or exophthalmic goitre; the 
former may be associated with arteriosclerosis, the latter with enlarge- 
ment of the thyroid gland. The presence of puffiness about the eyelids 
should be noted, as it occurs in Bright's disease, cardiac affections, 
arsenic poisoning, and traumatism. Do not make the error, as was 
done in the Harris case, of describing signs or symptoms as existing in 
the ocular apparatus when there is a glass eye! 

Position. — Instead of presenting parallel visual axes, one or both 
eyes may be deviated inward, outward, downward, or upward, con- 
stituting one of the various types of strabismus, a condition which may- 
aid in the diagnosis of toxic, cerebral, or nervous disorders. Conju- 
gate deviation of the eyes occurs in apoplexy. 

Color. — The color of the eyes is due to a blending of factors, vary- 
ing in value in every case, depending largely upon the quantity of 
pigment present. The several races have, as a rule, characteristic 
colored eyes: the negroes and the Mongolians, black; the Austra- 
lians and southern European races, dark; the Slavs, the Teutons, and 
the Scandinavians, blue. These peculiarities are worthy of note, as 
they may be of importance for purposes of identification. Color-blind- 
ness should be investigated by most careful microscopic study. By 
Daltonism is understood dyschromatopsia (congenital partial color- 
blindness) and achromatopsia (congenital total color-blindness). 

Conjunctiva. — Whitish patches, which may be congenital or ac- 
quired, are occasionally seen on the conjunctiva. If congenital they 
may be associated with moles on the face. The conjunctiva may be 
the seat of inflammatory conditions, which may be local or associated 
with some systemic disease. Note the variety of conjunctivitis present, 



8 4 



POST-MORTEM EXAMINATIONS 



and if any of the severe forms should be suspected an effort should be 
made to ascertain whether or not it is specific. Ecchymosis of the 
mucous membrane may occur in cases of injury to various parts of the 
eye, traumatic conditions affecting the skull, dura, or brain, and even 
systemic disease itself. The conjunctiva is one of the seats of jaundice, 
and it is the place where jaundice shows itself most plainly in the 
negro. Trachoma may have existed. 

Pupils. — Accommodation, convergence, and exposure to light, 
which during life produce alterations in the size of the pupils, after 
death do not affect it. In life, age, the color of the iris, and the char- 
acter of the refraction also influence it. Under ordinary circumstances 
the pupils should be equal, but variations may occur, depending upon 
the conditions and cause of death, a few of which will be here men- 
tioned. In fatalities due to chloroform the pupils may remain en- 
larged ; in opium poisoning they often expand shortly before or after 
death; and in cerebral hemorrhage they are generally irregular, 
depending upon the location of the clot. The pupil can be measured 
approximately by holding in front of it a rule marked in millimetres 
and noting the number of spaces its width occupies. This method is 
somewhat faulty and only approximately measures the width of the 
eye, but an accurate measurement can be made with the pupillometer. 

Cornea. — Note should be taken of the condition, curvature, and 
transparency of the cornea. Keratitis, ulcerations, and abscesses are 
common diseases of this locality. In old persons the arcus senilis is 
usually present. Besides its liability to disease, the cornea may be 
lacerated, torn, or injured, with or without the lodgment of foreign 
bodies. 

Sclera. — Examine its surface as to continuity and describe any 
lacerations or injury which it may have received. 

Iris. — The iris should be inspected for color, condition, and quan- 
tity of pigment. As this is a common seat of disease and operations, 
it should be especially examined for the presence of a coloboma, one 
of its most common malformations, which may be either congenital 
or acquired. The congenital form is due to the failure of the ocular 
fissure to unite ; it may be distinguished by the presence of the sphinc- 
ter, which in the acquired form has been excised along the margin of 
the coloboma, as after an iridectomy. The fissure is usually situated 
in the lower part of the iris, and is often associated with coloboma of 
the choroid. The iris should also be examined for the scars of opera- 



EXAMINATION OF THE EXTERIOR OF THE BODY g§ 

tions, for the information thus obtained is of value. Albinism is due 
to a lack of pigment in the choroid. 

Crystalline Lens. — Luxation or subluxation of the lens should be 
looked for. If present it may be either congenital or acquired.. 
Coloboma of the lens is accompanied by a similar condition of the 
choroid or iris. 

Optic Nerve. — This portion of the eye, together with the retina,- can 
best be examined with the ophthalmoscope. 

Growths. — The most common growths of the eye, and the parts 
generally affected are : Iris : angioma ; metastatic sarcoma, usually 
from the ciliary body; granuloma; and cysts. Choroid: sarcoma, 
most common of all tumors ; metastatic carcinoma, occasionally found ; 
naevus, rare ; cysts, rare. Ciliary body : sarcoma, common ; adenoma, 
occasional ; carcinoma, occasional ; nsevus ; cysts. Retina : glioma 
and cysts. 

Meningocele and herniae of the brain containing cerebrospinal fluid 
may be found protruding from the sinuses into the orbit. Dermoids 
of the orbit are frequently discovered, especially near the eyebrows; 
those of the eye occur at the corneoscleral junction. The so-called 
carcinoma originating from the lachrymal gland is usually an adeno- 
sarcoma. Lipoma of the eye, which may be either congenital or 
acquired, occurs in the fatty tissue. Tumors originating from the- 
bone are generally sarcomas or exostoses. +« 

Orbital Injuries. — As injuries are frequently received in and about 
the orbit, careful examination of this region should be made. Fract- 
ures through the orbit may cause, besides serious damage to the eye 
itself, grave cerebral complications. 

Orbital Diseases. — Diseases of the orbit are quite common and 
may be important, for they often cause meningitis. Caries, necrosis, 
and cellulitis are generally preceded by periostitis. 

After thorough examination of the eyes the lids should be carefully 
closed. 

Hair. — Examination of the hair may prove, especially in medico- 
legal practice, to be of importance. Not only the hair on the cadaver 
but also any hair found in the immediate vicinity of the body should 
be examined. Hair not belonging to the corpse demands inquiry as 
to whose it was and whence it came. In this way observations of 
value have been made and aided greatly in unravelling some of the 
world's deepest mysteries. The hair varies in color, length, quality, 



86 POST-MORTEM EXAMINATIONS 

and quantity in different individuals, and also according to situation 
on the same person. The head of the new-born infant is covered 
with fine, downy hair, a growth of the last two or three months of 
intra-uterine life. Shortly after birth it is shed and replaced by the 
true hair. The hair is one of the last tissues to yield to decay. The 
question of the growth of hair after death is a disputed one. Such 
apparent growth is most frequently caused by the retraction of the fat. 
In the new-born there is no medullary canal in the hair. (Vibert.) 
Human hair can be positively identified as such. 

Color. — The color of the hair should be noted and described ; also 
observe whether or not the color is uniform. As it depends princi- 
pally upon pigment, the color will vary in proportion to the quantity 
and variety of that pigment. Gray hair in adults is attributed to a 
diminution in pigment, and may be due to age, care, worriment, sudden 
fright, as after the San Francisco earthquake, burns, local inflamma- 
tions, systemic diseases, nervous disturbances, hardships, or exposure 
to cold, as seen in Arctic explorers. Gray hair in the infant is con- 
genital. Abnormal whiteness of the hair is a condition found 
in albinos. It may be complete or partial and is associated with 
loss of pigment in other organs. The examiner should not be misled 
by dyes. 

Length. — The length of the hair should be observed and approxi- 
mately measured. Long or short hair is characteristic of sex and of 
certain races. The longest hair is seen in the Indian, Chinese, , and 
Malay ; short hair in the Negro. 

Quality. — Various races have hair of characteristic texture. The 
Negro and the Bushman have crisp, woolly hair; among the Anglo- 
Saxon, Germanic, and kindred races the hair is smooth; Australians 
have soft, smooth, wavy hair ; the American Indian has coarse hair. 

Quantity and Distribution. — Hairs normally may be present on all 
exterior parts of the human body, except the palms of the hands, soles 
of the feet, glans penis, mucous membranes, and the ball of the eye. 
Some races are prone to excessive hair growth, as the " hairy men'' 
of the island of Yesso. Loss of hair, complete or partial, may be due 
to depilatories, pregnancy, disease, friction of clothing, or pressure. 
Baldness or moth-eaten appearance of the head, eyebrows, and mus- 
tache is seen in lues and myxcedema. Epileptic, idiotic, and insane 
persons generally have large growths of hair. Abnormalities of distri- 
bution have been recorded, and the examiner may often find either 



EXAMINATION OF THE EXTERIOR OF THE BODY 



87 



absence or overgrowth in certain localities. Under these conditions 
hair may be found in the interior of organs and neoplasms, especially 
ovarian dermoid cysts. 

Diseases. — The hair of the body is subject to various diseases, and 
therefore its condition should be carefully noted. Various forms of 
alopecia, tinea, and fungi may attack the hair. These conditions may 
be due to local or constitutional disorders. 

Injuries and Tumors. — Located under the hair tumors and various 
injuries may be present. Therefore pass the fingers through the hair 
of the scalp, and if it be at all thick part it, which aids in the discovery 
of wounds, hsematomata, and tumors which may be concealed. Should 
any be discovered, cut or shave the hair so as to examine them more 
carefully. If the head has been injured, it will usually be found that 
the hair has already been removed by the surgeon. The hair may be 
lost in X-ray workers. 

Nails. — When examining the nails attention should be paid to 
the material found under them, as it quite frequently is of medico- 
legal importance. The growth of the nails is regarded as one of the 
diagnostic signs of fetal maturity. They may be affected with favus 
( onychomycosis favosa ) . 

Anomalies. — The nails may be absent, atrophied, hypertrophied, 
brittle, discolored, cracked, etc. Congenital absence of one or more 
nails is usually associated with other malformations. Acquired ano- 
nychia may be due to trauma, nervous diseases, pyogenic infections, 
scar-leaving affections, as syphilis, and blood-stasis, as in cyanotic con- 
ditions. Another anomaly often met with is imperfect nail formation, 
resulting from dystrophia, in which the nail is usually opaque, dis- 
colored, brittle, and fissured. Certain diseases are sometimes noticed 
about the nails, as abscess, eczema, psoriasis, paronychia, syphilis, and 
professional dermatitis with paronychia. Traumatism confined to the 
nail or surrounding tissues is frequently met with and its nature and 
extent should be noted. 

Teeth. — The teeth should be examined as to anomalies, condition, 
and disease. 

Anomalies. — One or more teeth may be permanently absent, or 
supernumerary teeth may be present to such an extent that there are 
two dental arches in either one or both jaws. The teeth may be 
irregularly placed, often beyond the alveolar process. In examining 
the teeth notice should be taken of the condition of the palatal arch. 



88 POST-MORTEM EXAMINATIONS 

Condition. — Much can be learned from the condition of the teeth, 
as to care, neglect, habits, and disease. The teeth should be examined 
to see whether they are artificial. It is a noticeable fact that people 
from certain countries have particularly fine teeth regardless of the 
care taken of them. Caries of the teeth and the extent to which it 
involves the bone should be noted and, if possible, the cause deter- 
mined. Among other conditions phosphorus poisoning produces 
necrosis of the teeth and maxilla. Hutchinson's teeth are frequently 
seen and the condition is one of considerable importance. It consists 
in a single deep notch of the permanent upper central incisors, but 
the deformity is sometimes present in the molars when it is absent in 
the incisors. Dental tumors, such as epulis, sarcoma, osteoma, odon- 
toma, or dentigerous cysts, are occasionally found. 



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CHAPTER VI 

TECHNIC OF OPENING THE ABDOMINAL CAVITY AND THE TOPOGRAPHIC 
EXAMINATION OF ITS WALLS AND THE PARTS CONTAINED THEREIN 

Having completed the external examination of the body, all neces- 
sary instruments are placed in order and within reach upon a board 
or tray, 1 and the operative part of the autopsy is begun. 

The operator should stand so that when facing the body the in- 
cisions from above downward can be made with the greatest ease. 
This condition is best fulfilled by right-handed operators standing on 
the right side of the supine object, and left-handed operators on the 
left side. The body should be drawn well to the side of the table 
nearest the operator, the head resting on the top of the table and, if 
preferred, the shoulders supported by a block. 

With the knife held in as nearly a horizontal manner as possible 
(see page 43), clean, quick incisions (Fig. 55) should be made by a 
sweeping motion of the arm from the interclavicular notch (A) to the 
symphysis pubis (B), passing to the left of the umbilicus (C) in 
order to avoid any vessels going to or from the navel, the suspensory 
ligament, and a possible hernia or omphalomesenteric duct. Care 
should be taken at this time not to penetrate the abdominal cavity and 
thus injure the contained viscera, or to extend the incision to the 
external genitalia so as to disfigure them (Figs. 58 and 59). On the 
chest this primary incision goes down to the sternum, whereas on the 
abdomen it penetrates only to the peritoneum. In Europe the initial 
incision is usually started at the middle of the chin (symphysis menti) 
and continues down to the symphysis pubis ; for there, as a rule, only 
the poor who die in hospitals reach the post-mortem table, autopsies 
being seldom performed on the bodies of persons belonging to the 

1 A towel may be laid over the external genital organs and the upper part of 
the thighs, upon which the instruments to be employed in the performance of the 
autopsy are placed in the order of their use, with their handles towards the obdu- 
cent. An ordinary stool is frequently used abroad for this purpose. All instru- 
ments after use should be washed and returned to their proper places, so that no 
time may be lost in putting one's hand upon the one desired. This procedure 
also prevents possible mechanical injury to the operator, and loss of an instrument 
by being sewed up in the body. 

89 



9 o POST-MORTEM EXAMINATIONS 

upper classes. In this country the longer incision should be used only 
when great haste is necessary, as in cases of contagious diseases, such 
as diphtheria, or when the body is not to be seen again by relatives or 
friends. If the mentopubic incision be employed, it should not injure 
the thyroid gland, or other important structures of this region. A 
special Y-shaped incision is sometimes made here in order to avoid 
this, the incisions starting at the external ramus of the jaw and join- 
ing in the middle line about one inch above the interclavicular notch. 
The knife now follows underneath the skin, fat, and fascia over the 
lower border of the inferior maxillary bone, until the digastric muscle 
and the submaxillary glands are seen. The gland is then incised, the 
muscles being left in situ. The common carotid artery, internal jugu- 
lar vein, and pneumogastric nerve are now readily exposed. Care 
should be taken to avoid wounding the vein, as the resulting hem- 
orrhage hinders subsequent manipulations; such injury is especially 
to be guarded against on the left side in those cases where search is 
to be made for the entrance of the thoracic duct into the subclavian 
vein. 

The initial incision over the thorax is now carried down to the 
sternum in any place where this has not already been done, and the 
layers of skin, fascia, and muscles of the right side are quickly dis- 
sected away close to the ribs, freely exposing the costochondral articu- 
lation and some three inches of the sternal end of the clavicle. To do 
this the attachments of the soft tissues are made tense by drawing 
them away from the median line with the left hand (Figs. 60 and 
61), while long sweeping incisions are being made downward and 
laterally with the large section-knife. The left side may next be simi- 
larly treated, though in practice this is more frequently done after 
the central abdominal incision has been completed. Some necroscopists 
permit an assistant to prepare the left side while the operator is 
uncovering the right, but the time saved by this procedure is small 
and the danger of injury to those taking part is great. 

Should a pneumothorax have been diagnosed during life, the 
thoracic pocket made by elevating the skin-flap on the side of the 
pneumothorax is filled with water, and a puncture is made at the 
bottom through the costal pleura at the intercostal space between the 
sixth and seventh ribs at the axillary line. If a pneumothorax be 
present, bubbles of air will escape through the water, the visible supply 
of which will rapidly diminish. If the head be lowered and enough 



TECHNIC OF OPENING THE ABDOMINAL CAVITY gi 

water be used, this will finally escape from the mouth. It should be 
remembered, however, that a cavity in the lung opened accidentally 
by the knife would give the same result as that arising from a pneumo- 
thorax. Stanton finds the normal lowering of the column of mercury 
in the thoracic cavity to be three millimetres. In a case of a right- 
sided pulsating pyopneumothorax at Blockley in 1905 we found it 
was from twelve to fifteen millimetres. 

A note is now made as to the situation and character of any blood 
which may escape. The condition of the fat (panniculus adiposus) 
is considered, and its thickness noted at the nipple-line, beneath the 
xiphoid, and again three inches below the umbilicus. In atrophy the 
color of the fat becomes darker, changing to orange or reddish yellow. 
As a rule, the older the individual the darker in color is the fat, varying 
from straw-color in children to the dark yellow seen later on in life. 
Different species of animals have different colored fat, depending upon 
the difference in its chemic composition. The tissues here are often 
cedematous, as in general dropsy or erysipelas. 

The mammary glands may now be examined from behind, and, if 
desired, the glands of the axillae may be exposed by continuing the 
dissection of the pectoral muscles from beneath, as in Halsted's opera- 
tion for the removal of a cancerous breast. After the reflection of 
tissue over the ribs, the mammary gland on each side may be opened 
by four or five parallel perpendicular incisions, followed by several 
transverse ones, if deemed necessary. When the female gland is 
quiescent, it will be found to consist of dense, whitish, fibroid tissue, 
in which are a few pin-point, grayish-red spots (breast-grains). Dur- 
ing lactation it is larger, and the secreting tissue grayish red in color 
and granular, looking like a salivary gland. (Orth.) Fibrous 
tissue is found principally near the nipple. Pressure may cause an 
outflow of a yellowish, creamy liquid (which is not altogether unlike 
pus in its appearance) ; this should be at once examined under a low 
power of the microscope. The milk from the cow may be pink, — the 
so-called " bloody milk," — due to infection with the Bacillus prodigio- 
sus. 1 The following conditions of the gland should be thought of : 

1. Deformities: (a) depressed nipple; (b) mamma infantilis (hy- 
poplasia) ; (c) supernumerary glands or nipples. 2. Congestions 
and anaemias. 3. Burns. 4. Inflammations: (a) inflammation of 

1 Amer. Med., August 26, 1905. 



9 2 



POST-MORTEM EXAMINATIONS 



nipple; (b) fissures; (c) mastitis, acute; (d) abscess of connective 
tissue: (a) between skin and mamma; ( ,5 ) between muscle and 
mamma; (r) acini and ducts. (<?) Fistula: (a.) soft edge may 
mean milk fistula; (;2) indurated edge may mean mammary abscess; 
( r ) if broken and caseous, it is more likely tuberculous. (5) Granu- 
lomata, gummata, tuberculosis, and caries of ribs. (6) Changes of nu- 
trition. Remember in this connection that tumors of the genitalia or 
pseudopregnancy may cause an hypertrophy of the gland with a true 
secretion of milk, and that a similar result may occur in rare cases in 
the male, apparently from certain psychic influences. (7) Tumors, 
fibroma, carcinoma, echinococcus cysts, etc. 

The muscles now to be examined are those of the neck, chest, and 
abdomen. The external examination notes any marked changes in 
bulk. Both transverse and longitudinal sections are necessary to a 
complete study of the muscles, whose general characters should now 
be observed. The muscles may be atrophied or hypertrophied. 
Trophic change induced by affections of the anterior horns of the 
spinal cord may show itself in muscular atrophy and may be either 
inflammatory or degenerative, as in infantile paralysis, progressive 
muscular atrophy, and amyotrophic lateral sclerosis. The lesions 
may chiefly affect the peripheral and intermuscular nerves, as in lead 
paralysis with atrophy and in certain atrophies following diphtheria 
and other exanthemata; or the muscles may be affected primarily, as 
in the juvenile form of Erb's paralysis and pseudohypertrophic 
paralysis, or reflexly. as in the Charcot joint affections. (Dreschfeld.) 
Hypertrophy due to exercise increases the number of muscle-cells; 
when due to an increased blood-supply, the individual fibres are 
increased in size. Muscle is a highly organized tissue and does not 
reproduce itself with ease after injury. 

As the color of muscle is largely due to haemoglobin or some 
modification of it, it naturally varies according to the condition 
of the blood. Normally muscle is a bright red, but in anaemia it 
becomes paler, at times a grayish red. In general it may be said that 
the color and consistence of the muscles bear a distinct relation to each 
other : pale muscles are usually soft, while the darker muscles are 
more firm. The muscles are dry when much fluid has been carried 
off by the alimentary canal, as in typhus fever and cholera, and moist 
after the occurrence of disturbances of the circulation. Zenker in 
1864 described a form of colloid degeneration resembling the flesh of 



TECHNIC OF OPENING THE ABDOMINAL CAVITY 93 

fish in the flat muscles of the abdominal walls, occurring especially 
in enteric fever, though found in tetanus, scarlet fever, smallpox, and 
when near sarcomatous tissue. In diseases where the muscles have 
long been inactive a similar grayish, translucent appearance is at times 
observed. The dark meat of the fowl seems to undergo decomposi- 
tion sooner than the white, perhaps owing to its proximity to the 
intestines. The flesh of different animals possesses characteristic 
odors. Embalming fluids containing zinc bleach the muscles, while 
arsenic and strychnine preserve their natural color. Formalin hardens 
them. 

The general characteristics having been observed, the pathologic 
conditions to which these muscles are subject are not liable to escape 
detection. The more important morbid lesions are : 

(1) Hemorrhages. — These may result from trauma, wet cups, 
hypodermic injections, etc. The outflow from the cut veins often 
gives a good idea as to the color, fluidity, and odor of the blood. 
A special form of bleeding into the rectus may occur in typhoid fever, 
the so-called " haematoma recti abdominis." 

(2) Inflammations. — Among these are included: (a) Acute 
Myositis. — This is often suppurative, and may be primary, from 
trauma, or more usually secondary (as in the muscles of the chest) to 
pleural affections or (in the muscles of the abdomen) to pelvic suppu- 
ration. This inflammation does not, as a rule, produce true abscesses, 
but infiltrations in the muscle and separation of its fibres, which 
undergo a fatty or hyaline degeneration. Hematogenous inflamma- 
tion is by no means uncommon, perfect examples of miliary tubercles 
often being found if searched for in suitable cases, (b) Chronic Myo- 
sitis. — The interstitial connective tissue is increased so that at times it 
is visible to the naked eye, the muscle-fibres are atrophied, the color 
becomes a grayish red, and the muscles feel solid. This condition is 
generally associated with diseased states of the neighboring parts, — 
e.g., affections of the ribs, pleurae, cervical glands, etc. There is a 
syphilitic form of fibroid myositis. Glanders and actinomycosis may 
affect the muscles, (c) Parenchymatous Myositis. — The muscle is 
paler than normal. All the various forms of degeneration — as cloudy 
swelling, hyaline, or fatty — affect muscle, and microscopic examina- 
tion, as in acute primary polymyositis, is necessary in order to deter- 
mine their presence, (d) Bony formations are sometimes found, as 
the " drill" bones in the shoulder muscles and the " rider's" bones in 



94 POST-MORTEM EXAMINATIONS 

the adductors of the thigh. (Ziegler.) Progressive ossifying myositis 
is a rare disease, running a chronic course, which especially attacks 
young people; those thus affected are sometimes exhibited in dime 
museums as " petrifying" persons. 

(3) Parasites. — The most important parasite is the Trichina 
spiralis, which is found most frequently in the muscles of the neck and 
in the intercostals near to the attachment of the diaphragm; in old 
cases the calcified capsules may be easily recognized as small, white, 
oval bodies, which when present in large numbers look and feel like 
grains of sand. In the muscle itself the site of election is close to the 
spot where the tendon unites with the muscle proper. In order to see 
the parasite the capsule should be dissolved with hydrochloric acid. In 
its early stages this mass is not readily discovered, and its detection 
is made easier by pressing a teased portion of muscle between two 
glass slides and observing it by transmitted light with a hand lens. 
In all doubtful cases the aid of the microscope should be invoked. 
Measles (cysticerci) and hydatids may also be found in the muscles. 

(4) Tumors. — Primary tumors are rare; they usually originate 
from the connective-tissue septa. 

The abdominal cut is now deepened between the umbilicus and 
the xiphoid cartilage until a small portion of the peritoneum is ex- 
posed. 1 This membrane should then be carefully opened, and if it be 
desired to determine the presence and character of any gas present in 
the abdominal cavity the incision is carried down to the peritoneum, 
either two inches above or the same distance below the umbilicus, and 
the abdominal walls are elevated with the fingers or a tenaculum so as 
to form a pouch, into which water is poured. A test-tube is then filled 
with water and inverted over the pouch, and a small incision is made 
through the peritoneum under the mouth of the test-tube so as to 
allow any escaping gas to enter it. The test-tube is tightly closed be- 
fore all the liquid has run out of it by pressing a thumb or finger 
up against its mouth, and placed in a shallow dish containing sufficient 
water or mercury to seal the open end of the tube. It is then trans- 
mitted to the chemist for examination. If a lighted match be held 
close to the point where a knife is pushed into the chest, any escap- 
ing gas deflects the flame. It should be remembered that certain gas- 
forming organisms may be the cause of the gaseous collection in 



1 For the technic of a bacteriologic examination see Chapter XXIII. 



TECHNIC OF OPENING THE ABDOMINAL CAVITY 



95 



serous cavities. The recent discovery of hitherto unknown elements 
in the air makes the study of aggregation of gases here an extremely 
interesting one. If the gas has an acid odor, an opening in the 
stomach is to be suspected. 

If fluid be present, the abdomen usually protrudes, the sides are 
flattened, and the superficial veins much dilated, a caput Medusae form- 
ing about the umbilicus. Percussion will often reveal its presence, and 
when found a mental note should be made carefully to examine the 
oesophageal veins, as a fatal hemorrhage may occur from their rupt- 
ure, a fact which I have more than once personally substantiated at 
autopsies. In ascites just enough of the fluid should be removed to 
facilitate the determination of the height and location of the dia- 
phragm, which may be done by introducing the hand, palm upward, 
or a steel sound, into the abdominal cavity and following the under 
surface of this muscle as far as possible. When the tips of the fingers 
or the end of the sound reach the point of least resistance, this spot 
should be sought for with the other hand from without. The vault 
of the diaphragm extends to the upper border of the fifth rib on the 
left side and to the fourth rib or fourth interspace on the right. Both 
sides are measured in the line of junction of the ribs with the costal 
cartilages. The greater height on the right is due to the liver, which 
forces the diaphragm upward, and in excessive hepatic hypertrophy 
or in a large subdiaphragmatic abscess the diaphragm may reach even 
as high as the level of the second rib. Increase in the abdominal con- 
tents, as by tumors, pregnancy, hypertrophy of the spleen, etc., elevates 
the diaphragm, while augmentation of the thoracic contents naturally 
pushes it downward. Along with the depression is a sense of fluctua- 
tion in cases of hydro- or pyothorax. The position of the diaphragm 
in a new-born child helps to determine whether or not it has breathed. 
Before respiration has occurred, the summit is found on a level with 
the fourth rib on the right side and on a level with the fifth rib or the 
fourth intercostal space on the left. After full expansion of the lungs 
has taken place, the summit is found at the fifth or sixth rib on the 
right and at the sixth rib on the left (Orth). 

The opening may now be somewhat enlarged and additional fluid 
removed with a syringe, cup, or large pipette, measured, and its char- 
acter noted. The remaining portion may be collected from the various 
folds and pouches in the peritoneum with a sponge or small cup. 
Normally, there is little or no fluid present in the abdominal cavity; 



9 6 POST-MORTEM EXAMINATIONS 

its color may be lemon-yellow, red, or brown ; icteroid or milky ; 
watery, thick, gruel-like, or even semisolid. The removal of liquid 
at this stage of the operation prevents its admixture with blood, 
as from an accidental incision into the liver while cutting the costal 
cartilages, or with other fluids of the body, such as those from the 
pericardium, the pleura, the bladder, or various portions of the intes- 
tinal tract. Ascites is especially associated with Bright's disease, 
chronic heart disease, chronic lung disease, anaemia, portal obstruction 
due to cirrhosis of the liver, chronic passive congestion of the liver, 
inflammatory adhesions, etc., tumors, displaced or hypertrophied vis- 
cera, as the enlarged spleen of malaria or leukaemia, and peritonitis, 
especially when tuberculous. The serous membrane is apt to be lustre- 
less, whitened, and thickened, especially the capsules of the spleen and 
liver, if the disease has lasted any length of time. The intestines are 
frequently matted together by fibrous adhesions, and the uterus and 
adnexa often show a similar condition, especially when the peritonitis 
is of a tuberculous nature. 

In cases of increased amount of fluid it is of importance to dis- 
tinguish between a serous transudate and an inflammatory exudate. 
When large amounts of pus and fibrin are present, the differentiation 
of these two conditions is quite easy. Difficulty arises when a 
clear, watery fluid is found in which minute flocculi are seen, as these 
may be either small flakes of fibrin and pus-cells or collections of 
washed-off endothelial cells. 1 Much fibrin is an evidence of inflam- 
matory changes, and there is a greater tendency to coagulation. The 
differential points may be summarized as follows : 

Transudate. Exudate, 

i. Fluid clear and watery, though it may i. Fluid serous, thick, ropy, and at times 
form a spontaneous clot ; no odor. foul smelling. 

2. Usually alkaline reaction. 2. Often acid reaction. 

3. Specific gravity usually below 1.016. 3. Specific gravity generally over 1.016. 

4. Albumin usually below two per cent. 4. Albumin may exceed three per cent. 

5. No bacteria or their products present. 5. Contains organisms, toxins, globuli- 

cides, etc. 

6. Urea 2 and cryoscopic index low. 6. Urea and cryoscopic index high. 

7. Flocculi are thin, veil-like, transpar- 7. Flocculi are thick, opaque, and of a 

ent, and of a gray color. grayish-white color. 

1 Miller, Amer. Med., November 12, 1904, shows the difficulties of differen- 
tiation from a study of seventy-five cases. 

2 Ulrici, Centralbl. f. inner e Med., no. 16, 1903. 



TECHNIC OF OPENING THE ABDOMINAL CAVITY 



97 



Transudate. Exudate. 

8. In a transudate the globules present 8. A drop of an exudate coming in con- 

are in too small an amount to react tact with glacial acetic acid causes 

thus. 1 a turbidity. 

9. Under the microscope (cytologic ex- 9. Microscope shows the flocculi to con- 

amination) the flocculi are seen to sist of fine threads and polynuclear 

be made up of flat cells with leucocytes, the nuclei of which ap- 

large nuclei (endothelial cells) and pear more distinctly on the addition 

lymphocytes, the latter condition of acetic acid, 
appearing to denote especially pri- 
mary tuberculosis. 

Milky exudates are of two kinds, fatty and chylous. The former 
variety has been found in connection with peritoneal and mesenteric 
cancer, and is recognized by the fat-globules seen on microscopic ex- 
amination. Slight amounts may be due to the fact that the patient 
was on a milk diet or was suffering from lipsemia, a dyscrasia also 
found in diabetes (Osier). A chylous exudate results from the per- 
foration of the thoracic duct or the receptaculum chyli. 

Suppurative exudates, due to perforation of the intestine, are thick, 
yellowish, and contain much fibrin, which is deposited on the perito- 
neum and bowel in layers. The odor, which is peculiarly nauseating, 
may be due to the Bacterium coli commune; the process is usually 
acute. 

A hemorrhagic exudate or fluid may be non-inflammatory, as 
that arising from trauma (rupture of the liver or spleen or extra- 
uterine pregnancy), from cirrhosis of the liver, from cancerous and 
tuberculous peritonitis, etc., or it may be inflammatory. Pure bile, 
most frequently mixed with blood, may be found in the abdominal 
cavity after injury to the gall-bladder or the bile ducts. 

One finger is now introduced into the opening previously made 
in the abdominal cavity, the flap of the skin is elevated, and the incision 
is somewhat lengthened. Next the index- and middle fingers, point- 
ing downward, of the left hand, held V-shaped (Fig. 62), palm up- 
ward, are thrust under the abdominal wall in order to raise it above 
the intestines so as to prevent injury to them while the cut is continued 
to the pubes, the fingers thus acting as a director. Then a similar 
incision is made up towards the xiphoid cartilage. If there be much 
meteorism, the index-finger of the left hand can be introduced and 
held against the parietal peritoneum. If scissors be used, the lower 

1 Rtvalta, 77 Policlinico, no. 6, 1904. 
7 



9 8 POST-MORTEM EXAMINATIONS 

blade may be guarded by the ringers of the left hand when the cut is 
made. Another method is to make the incision by strong traction up- 
ward on the right abdominal flap while the part is well elevated above 
the intestine. The cutting should preferably be done from within out- 
ward, great care being taken not to puncture or injure any of the 
abdominal viscera, especially the stomach and bladder. After noting 
the location and distribution of adhesions as pointing to previous 
inflammatory conditions, it is well to break up such adhesions with 
the fingers. Should the intestine be accidentally opened, it is best to 
stop at once and tie both above and below the opening in order to pre- 
vent the escape of the contents of the bowel into the peritoneal cavity. 

If it be desirable to enlarge the opening in the abdominal wall 
(Fig. 55), a second incision (D E) may be made, at right angles to 
the first one and about three inches above the umbilicus, or the rectus 
muscle on one or both sides of the body may be divided subcutaneously 
a little above Poupart's ligament (F and G). Should there be a pene- 
trating wound of the abdomen, as from a dagger or a previous cceliot- 
omy, the abdominal incision may be changed at will (Figs. 56 and 57). 

When the contents of the stomach are found in the peritoneal 
cavity, care must be taken to determine whether their escape was due 
(a) to post-mortem digestion, or autopepsia, (b) to trauma, (c) to 
perforation from a gastric ulcer or from chemic erosion of the coats 
of the stomach by poisons, etc., (d) to the presence of (b) and (c), 
with the factor (a) as the real cause. In the first case the ingesta are 
usually widely distributed throughout the abdominal cavity, though 
most plentifully in the immediate neighborhood of the perforation, 
the rent is large and irregular, and the walls are soft and slimy ; while 
in disease the opening is apt to be small and circular and surrounded 
by evidences of hemorrhage and peritonitis. Undigested food enters 
the peritoneal cavity through a breach in the gastric wall; when 
digested food or faeces are present the seat of injury is the duodenum, 
or bowel, and, if the latter, the material is usually stained with bile. 
Autodigestion is especially frequent in cachectic children. Intestinal 
worms may escape into the peritoneal cavity through perforations in 
the bowel. From the fact that the autopsy is usually performed some 
time after death, the appearances presented by a gastric ulcer are 
different from those seen at an operation during life, for, inter alia, the 
serous wall of the ulcer may have undergone post-mortem digestion. 
Ten to twenty ounces of a five per cent, formaldehyd solution may be 



TECHNIC OF OPENING THE ABDOMINAL CAVITY 99 

introduced within five hours after death to prevent this condition, when 
the postmortem in gastric cases, as of ulcer, must be delayed. 

The suspensory ligament of the liver may be studied at this time. 
Should there be an omphalomesenteric duct it must be carefully fol- 
lowed out to its diverticulum in the ileum. 

Foreign bodies, which may be calcified, are sometimes found free 
in the abdominal cavity ; they may be derived from torn-off appendices 
epiploicae or polypoid tumors. Surgical instruments and appliances, 
such as sponges, artery-forceps, scissors, and gauze compresses, have 
been discovered in the abdomen after the performance of operations, 
v. Neugebauer 1 citing 195 such instances. In Europe severe punish- 
ment has been meted out to surgeons for their forgetfulness in this 
respect. 

The abdominal cavity being thoroughly exposed, the most striking 
abnormalities therein are to be noted. Transposition of the viscera 
would at once be observed. The most marked displacements of abdomi- 
nal organs seen by the writer have been in cases of Pott's disease and 
diaphragmatic hernise. 

The omentum ordinarily comes first under observation. Normally 
the omentum is non-adherent to the intestines except at its point of 
attachment; in purulent peritonitis it may be markedly adherent to 
the peritoneum covering the intestinal tract, creamy or plastic lymph 
appearing in streaks throughout its structure. The omentum may 
form a part of every variety of abdominal hernia; it may be 
present alone in the hernial sac, or the intestines may become 
strangulated by passing through an opening in it. Trauma or atrophy 
of the connective tissue may produce such openings, some of which 
may be of large size. The amount of fat deposited between the layers 
of the omentum varies considerably, being in some cases practically 
absent and in others measuring as much as half an inch in thickness. 
During health the omentum is rich in fat, which disappears early and 
rapidly in emaciation. Normally the layers are readily separable, and 
when spread out form a beautifully thin, transparent membrane, with 
irregular deposits of fat, and showing the blood-vessels partly filled 
with blood. It is a common seat of fat necrosis, tuberculosis, and 
generalized cancer ; in the last two conditions it may be so contracted 
upon the transverse colon or the greater curvature of the stomach 



1 Centralbl. f. Gyn'dk., 1903, vol. xxvii, no. 

Lore. 



IO o POST-MORTEM EXAMINATIONS 

as to be hardly visible, and separable therefrom only with the greatest 
difficulty. Enlarged glands, encysted parasites, infarcts, pins, super- 
numerary spleens, etc., may be found. 

The serous covering of the stomach and intestines should be 
minutely inspected, as the play of colors is very varied and the infor- 
mation gained from this examination is often of great importance. In 
thrombosis of the mesenteric vessels the gut may be gangrenous for 
ten feet or more. Miliary tubercles are found opposite tuberculous 
ulcers and extend along the lymphatics; they are also seen on all the 
other portions of the peritoneum, often being wide-spread in tuber- 
culous peritonitis. Small, yellowish, creamy collections of lymph, with 
dilated lymphatics, are seen if death occurred several hours after eat- 
ing; these are physiologic and not pathologic products, but I have 
known them to be mistaken for miliary tubercles and even for carci- 
nomatous growths. The presence of typhoid ulcers may be recognized 
by a congested area along the length of the intestine. The location 
of the vermiform appendix should always be noted, and Virchow's 
dictum (first published in 1875, though practised long previously) 
should be remembered : " At least in every case of inflammation of the 
peritoneum the appendix is to be carefully examined." In the female 
an inspection should be made of the uterus and its adnexa. The 
mesenteric glands, especially those near the ileocecal valves, are to be 
carefully looked at; they are greatly enlarged in typhoid fever, in 
which they sometimes undergo suppuration, and in children dying 
from inanition, where they appear as red nodes, often running together 
into conglomerate masses. 

The transverse colon may assume odd shapes and positions ; thus, 
it may be bent like the letter U and extend as low as the bladder ; it 
may or may not drag down the stomach. In some cases it forms 
peculiar S-shaped curves; in others the hepatic and splenic flexures 
may be markedly deficient. These malpositions are supposed by some 
to be especially common in the insane. In an infantile form 
there may be no descending colon. Cotton which has been inserted 
in the rectum or vagina by the nurse or undertaker to prevent the 
escape of fecal or other matter may be mistaken for a foreign body 
and may possibly have caused displacement of neighboring parts. 

The stomach is subject to marked changes in size and situation, 
as from hour-glass contracture, tumors, ulcerations, etc. In the babe 
its situation is nearly vertical. This viscus is often filled with gas 



TECHNIC OF OPENING THE ABDOMINAL CAVITY IO l 

formed after death; a peculiar sound may sometimes be heard when 
the gas is expelled by pressure from without. One does not realize 
the extent to which the stomach may be distended by food and drink 
until he has made post-mortem examinations of the viscera of inebriates 
and persons accidentally killed soon after they had eaten hearty meals. 
The capacity of the stomach may be estimated by filling it with water 
and measuring the amount; but the method is not accurate and may 
destroy the appearance later on of a gastric ulcer. 

All the openings through which hernias are apt to occur are next 
to be examined, the most common varieties of hernia being inguinal 
hernia in the male and femoral and umbilical herniae in the female. 
Other forms of rupture are those into the canal of Nuck, the obturator 
foramen, or the sciatic notch ; into the various fossae about the caecum 
or the fossa jejunalis; into new fossae formed by bands of adhesions, 
as from extra-uterine pregnancy; from solutions of continuity in the 
mesentery; retroperitoneal (foramen of Winslow) ; crural; diaphrag- 
matic, which is often congenital, but may be due to traumatism; be- 
tween the rectus abdominis muscles and through Petit's triangle ; after 
operations, especially those on the appendix, etc. 

Volvulus and invagination are not infrequently seen. True in- 
vagination is to be distinguished from a form which often occurs in 
children just previous to death; in the latter cases multiple lesions 
(sometimes as many as fifteen or twenty), produced during the agonal 
period, are found. There is a peculiar form of invagination in which 
the ileocaecal valve draws the ileum down into the caput coli; this 
condition when extreme may even cause the ileocaecal valve to appear 
at the anus. Philipowicz 1 finds that volvulus of the sigmoid occurred 
in one-third of all such cases reported. 

Note if the gall-bladder is distended or contracted; see if it 
extends below the liver, and, if so, to what extent. Feel it gently and 
note if any gall-stones are contained therein. Insert a probe into the 
gall-ducts to determine whether or not they are patent. Should a bac- 
teriologic examination of this part be wanted, it is now to be made. 
Follow with the hand the upper surface of the liver, first of the right 
lobe and then of the left, in order to determine their extent, noting the 
height and the distance to which they extend below the ribs. The tips 
of the right and left lobes of a large liver almost meet at the vertebral 

1 Arch. f. klin. Chir., 1903, vol. lxx. nos. 3 and 4. 



I02 POST-MORTEM EXAMINATIONS 

column. The left lobe may extend downward like a beaver's tail, and 
as a result of tight lacing the whole organ may be divided into an 
upper and a lower portion by bands of connective tissue containing 
the biliary vessels and a few liver-cells. The right lobe may be con- 
stricted and a portion become a floating lobe. Accessory lobes are 
very common; some of them even take the form of supernumerary 
livers. This condition may be congenital, but it is more frequently 
due to syphilis. In one of my syphilitic cases the liver was made up 
of more than thirty lobes, in shape resembling a bunch of flattened and 
distorted hydatid cysts. The liver should next be slightly raised, the 
pylorus examined, and the tips of the fingers used to determine the 
presence of calculi in the bile ducts and gall-bladder. 

When no extensive pathologic lesions exist, the situation of the 
pancreas may readily be determined by remembering the close connec- 
tion of its head with the concavity of the duodenum. One of the strik- 
ing pictures seen in opening the abdomen is the so-called " Zucker- 
guss" or " porcelain" liver and spleen. This condition is seen in 
ascites and is associated with accumulations of fluid in other parts, 
as in the pericardium and pleura. 

During this superficial examination of the abdominal cavity any 
needful departure from the ordinary routine may be planned. Thus, 
in a case of cancer of the head of the pancreas it may be advisable 
later on to remove this organ along with the stomach, the duodenum, 
or even the liver. Again, in the case of a child or when there is not 
time for a careful dissection, all the organs of the abdominal cavity 
may be removed en masse. One must always be on the lookout for 
supernumerary organs, for they occur in the most unexpected places, 
as pulmonary tissue below the diaphragm, adrenal tissue in the liver, 
and pancreatic tissue on the wall of the stomach. 

To repeat, the relative positions of all the abdominal tissues should 
be observed, any departure from the normal noted, and a careful search 
made for foreign growths, attachments, anomalies, etc., none of the 
organs being at this time removed or their relations so disturbed 
as to prevent further examination, should such be required in the 
future manipulation of the body. 



CHAPTER VII 

TECHNIC OF EXPOSING THE THORACIC CAVITY AND THE CRITICAL 
EXAMINATION OF THE PARTS CONTAINED THEREIN 

Method of Opening the Thorax. — After the superficial ex- 
amination of the parts contained in the abdomen is completed, the 
organs of the thoracic cavity may be exposed to view in the following 
manner: The second to the tenth costal cartilages on the left side are 
cut through, one by one, from above downward, at a point close to 
the attachments of the osseous portions of the ribs. For this purpose 
a heavy cartilage-knife is employed, which should be held as nearly 
parallel to the chest surface as possible, so that as the blade cuts 
through one cartilage it strikes the next one, thus preventing injury 
to the organs beneath. In order that the most useful portion of the 
knife for future cutting may not be dulled by this procedure, the incis- 
ing may be done by the part of the blade near the handle. Or the knife 
may be introduced into the intercostal space beneath the rib that is 
about to be cut, using the next lower rib as a fulcrum and cutting from 
within outward (Fig. 63). As the incision proceeds downward the 
ribs are severed more and more towards the axillary line, thus making 
the opening in the chest larger and larger. In cases where the carti- 
lages are calcified it may be best to use a costotome or a saw for their 
division, in which event the ribs might as well be cut in their osseous 
portions in order to allow more room for subsequent manipulations. 
Care must be taken, however, not to injure one's self later on by the 
jagged edges left behind, if this mode of procedure be adopted. The 
second to the tenth ribs on the right side are now severed in a similar 
manner. 

The right clavicle is next separated from the sternum. As its 
head articulates with the latter bone and the cartilage of the first rib, 
the collar-bone is grasped with the left hand and its inner end is 
moved to and fro, or an assistant may produce the same result by 
moving the whole arm. In this way the line of articulation is easily 
made out, and permits the part to be disarticulated by cutting down- 
ward and slightly outward until the first rib is reached (Fig. 64), 
the incision being continued outward in the direction of the shoulder 

103 



104 



POST-MORTEM EXAMINATIONS 



along the under border of the clavicle and the upper part of the first 
rib for at least two inches. The first rib, which is generally calcified, 
is now cut through with a knife from below outward or from above 
inward (Fig. 65). Or the costotome may be employed for this pur- 
pose (Fig. 66). 

The next procedure is to grasp the breastplate from below and to 
make traction upon it upward and towards the right. Beginning on 
the left side at the lowermost incision in the ribs and keeping close to 
the lower border of the sternum, cut through the underlying tissues — 
chiefly diaphragm — separating the thoracic from the abdominal cavity, 
with short transverse strokes of the knife (Fig. 6j) , elevating the 
sternum more and more as the tissues are separated. All the lower 
attachments having been cut with care so as not to open the peri- 
cardium, the breastplate is now elevated and pulled towards the left. 
Any uncut sternocostoclavicular attachments on the right side are 
thereby made tense, and being easily discovered are severed, the 
knife passing next along and beneath the upper part of the sternum 
(Fig. 68). The tissues being made more and more tense by raising 
and rotating the sternum, its under surface now appears uppermost 
and is turned away from the operator. The right first rib is now cut 
through and the left clavicle is disarticulated either from below 
(Fig. 69) or from above as seems easiest to the operator. Owing to the 
increased room and the greater leverage afforded by torsion of the 
sternum upon the left sternocostoclavicular attachment, this procedure 
usually requires very little use of the knife and is much easier of 
accomplishment than on the opposite side, the force applied by the 
rotation being sometimes sufficient for the sternum's removal. The 
appearance of the breastplate, after its separation from the body, is 
shown in Fig. 70. If an aneurism or tumor be found adherent to the 
ribs or sternum, its point of attachment is preserved by sawing through 
the bone at some distance therefrom. 

In removing the sternum great care is necessary in order to avoid 
cutting the innominate or internal mammary veins which lie beneath 
its upper end and the clavicle. In Bavaria and Wiirtemberg, in order 
that these vessels may not be injured and the part bathed with blood, 
the regulations for the performance of medicolegal autopsies direct 
that the lower end of the sternum, when freed, shall be strongly ele- 
vated, and the sternoclavicular connection and the first rib cut from 
the under side, or the breast-bone may be sawed through below the 




Fig. 66. — Method of incising the first rib and the sternoclavicular articulation with the costotome. 




Fig. 67.— All the ribs of the right side have been severed, the sternoclavicular attachment to the first 
rib remaining intact on the left side. The lower portion of the sternum is elevated and traction made on 
the diaphragm, which is cut as close as possible to the lower border of the sternum. 




Fig. 68. — The lower border of the sternum having been freed, the breastplate is elevated and pulled 
upward and towards the left. The left sternoclavicular attachment is thus easily discovered, and is cut 
through. The first rib is then detached. Care is especially taken on this side not to injure the subcla- 
vian vein, not only on account of the blood escaping upon adjacent parts, but also owing to the difficulty 
after disturbance of the parts in finding the entrance of the thoracic duct into the vein. 




Fig. 69.— The sternum is here practically ready to be removed from the body. The knife is cutting 
any attachments which may not previously have been severed in the neighborhood of the left sterno- 
clavicular articulation. 




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Fig. 72.— Appearance of chest and upper part of abdomen after the opening of the body. 



TECHNIC OF EXPOSING THE THORACIC CAVITY 



I05 



attachment of the first rib, leaving it and the sternoclavicular articula- 
tion intact. The writer does not approve of the method often used, 
after cutting the ribs, of breaking the sternum by turning it backward 
just below the clavicular attachment. Though it avoids the escape 
of blood from the veins, it leaves a serrated edge likely to injure the 
operator's hands in future manipulation and gives less room for 
the subsequent examination of the thoracic cavity and the neck. Some 
careless operators do- not even remove the bone, but while still attached 
turn it back over the face. Do not forget to return the sternum to 
its proper place in the restoration of the thorax, an error often made 
and not discovered until the body is sewed up. 

In order to protect the hands of the operator from injury, the skin 
flaps are now wound around and beneath the exposed clavicles and 
ribs (Fig. 71), or these may be covered with a strip of adhesive plaster 
or of antiseptic gauze held in place by a stitch around an upper and 
lower rib. Cotton should not be used for this purpose, as portions 
become detached and adhere to the tissues of the body, thus interfering 
with later manipulations. 

Sternum and Ribs. — The examination of the sternum and ribs 
may now be undertaken. Their shape is often altered, as in Pott's 
disease, pigeon-breast, emphysema, perforated sternum, rickets, occu- 
pation deformities (such as pressure atrophy in shoemakers, caused by 
holding the shoe against the breast), etc. The ribs may be deficient in 
number, and supernumerary ribs (e.g., cervical ribs, which may cause 
brachial neuralgia) or malposed ribs, may be found. The tenth rib 
is sometimes markedly movable in neurasthenics. Tuberculous caries 
of the sternum, often secondary to caseation of the mediastinal lymph- 
glands, or metastatic tumors may be present, or an aneurism may 
cause pressure atrophy (erosion) or even perforation of this bone. It 
is this form of saccular aneurism which is sometimes treated by wiring 
and by electrolysis. Fracture is not common, but may be found, as 
between the second and third costal cartilages, — i.e., near the junction 
of the manubrium with the gladiolus. The ensiform appendix of the 
sternum is sometimes curled upward and outward like a hook in cases 
of hepatic hypertrophy or tumor. When this condition is present 
with atrophic cirrhosis of the liver, it indicates a previous enlarge- 
ment of that organ (Suchard). The marrow of the sternum (best 
exposed by a longitudinal opening), which is normally of a slightly 
reddish, lymphoid appearance, may present the changes characteristic 



106 POST-MORTEM EXAMINATIONS 

of leukaemia, anaemia, tuberculosis, etc. In the last stages of car- 
cinoma the sternum and ribs are at times so infiltrated with cancerous 
deposits, especially when the breast is affected, as to break readily. 
The ribs may show evidence of rhachitis by the presence of the 
rhachitic rosary, in which case a section of the rounded enlargements, 
especially where the cartilage joins the bones, will show the changes 
peculiar to rickets. In old persons the entire cartilage may be calcified 
or even ossified. The central substance of the ribs sometimes under- 
goes atrophy and absorption, leaving a large canal filled with blood. 
The cartilage may contain cystic cavities. Coplin has recently shown 
that the intercostal muscles are apt to show dissociation of fibres, 
leucocytosis, infiltration, granulation, etc., in disorders affecting the 
lungs and pleurae. 

Clavicles. — Each clavicle may now be freed almost to its 
acromial attachment, the arm extended at a right angle to the body, 
and the region of the subclavian vessels and brachial plexus readily 
exposed and studied, especially for anomalies. In one of my cases — 
a stab-wound of the shoulder — I found that the brachial plexus had 
been ligated by a competent surgeon in mistake for the artery. Should 
it be desired to remove these vessels, the vein may be tied and the whole 
mass incised beyond this point preparatory to their removal in toto. 
The ending of the thoracic duct on the left side may now be studied, 
or this may be done after the removal of the heart and lungs. 

Mediastinum. — The condition of the mediastinum is to be noted, 
especially as to emphysema in the areolar tissue, tumors (usually 
secondary), the ductus arteriosus, the thymus, and the peribronchial 
and other lymphatic glands. Except in the young, the latter are pig- 
mented, and for this reason have more than once been mistaken for 
melanotic sarcoma. They are often tuberculous, and may be infil- 
trated with cancerous or sarcomatous matter. In this situation 
emphysema is quite often produced after death by the removal of the 
sternum during the autopsy or by decomposition. When the lung is 
lacerated, the emphysema is more extensive and may even involve the 
neck. Hemorrhage into the mediastinum may be due to trauma, rupt- 
ure of an aneurism, or bleeding from the oesophageal veins, to phos- 
phorus poisoning, or to acute yellow atrophy of the liver. An abscess 
or chronic mediastinitis, marked by fibrous thickening and density of 
the connective tissue, may be found. The latter usually occurs in 
conjunction with a fibrous pericarditis (mediastinopericarditis), and 



TECHNIC OF EXPOSING THE THORACIC CAVITY 



107 



is of importance on account of its influence upon the heart action 
(Orth). 

Thymus Gland. — This weighs about 13.75 grammes at birth, 
and increases in size until the end of the second year, when it weighs 
about 26.2 grammes. It then gradually diminishes, and after puberty 
is normally absent, though the gland should always be sought, as it 
may, at times, be found in the normal adult. Aberrant glands are 
sometimes found, as in the neck or just above the diaphragm. In cer- 
tain pathogenic conditions, as acromegaly, myxcedema, and exophthal- 
mic goitre, the thymus may be present, and then it is more of a yellow 
color than the normal grayish red. Even when the thymic tissue 
itself has disappeared, its former situation may usually be located by 
an increased formation of fibro-adipose tissue. Hemorrhagic areas 
are often found in the thymus glands of stillborn babes. Pus may 
sometimes be present, having developed in situ or having found its way 
into the mediastinum along the plane of the cervical fascia. Abscesses 
are seen at times in syphilitic children, but great care is necessary in 
making the diagnosis of suppuration, as the altered appearance of the 
normal juice of the thymus gland after it has undergone post-mortem 
change may simulate this condition. Sudden death in infants may be 
due to pressure symptoms from an unduly enlarged thymus. Sarcoma, 
endothelioma, angioma, and dermoids are also found here. 

Thyroid and Parathyroid Glands. 1 — Both lobes and the isth- 
mus of the thyroid may at this time be examined in situ. If preferred, 
the gland, together with the tongue, velum palati, epiglottis, oesopha- 
gus, trachea, parathyroids, carotids, intercarotid bodies, etc., may be 
removed in a single piece (see page 122) and studied subsequently 
detached from the body. The thyroid body may show enlargement 
due to parenchymatous, telangiectatic, or interstitial changes, or be 
associated with hypertrophy of the thymus and dilatation and hyper- 
trophy of the heart. The colloid material may be considerably 
increased in amount and deposits of lime sometimes occur. Con- 
genital goitre is now and then observed. The colloid goitre may 
become cystic and form cystic adenoma, into which hemorrhage may 
later occur. Thyroiditis is found in some of the infectious fevers, as 
diphtheria. Myxcedematous degeneration, or cachexia strumipriva, 



1 For a recent book upon this subject, see Richardson's Thyroid and Para- 
thyroid Glands, 1905. 



I0 g POST-MORTEM EXAMINATIONS 

is due to disease or removal of the gland. In cretinism, due to a 
goitrous thyroid, the body is small, the head large, the countenance 
heavy, the abdomen protruding, kyphosis is often present, the lips are 
thick, the skin and mucous membranes are dry and pale, and the hair is 
coarse and lustreless. Primary malignant tumors of the thyroid are 
seen, a mixed-celled sarcoma, at times angiomatous, being more com- 
mon than cancer. Salmon and trout not infrequently show a cancer 
of the thyroid gland. 1 There may be accessory thyroid glands, as 
at the base of the tongue, and these may be affected with goitre. 
Iodothyrin is a normal constituent of the thyroid, and is especially 
abundant in old age and after the administration internally or the 
application externally of substances containing iodin. It may appear as 
such or be combined with albumin and globulin. ( Baumann. ) A large 
number of the older reported cases of iodism were said to be Basedow's 
disease. A curative serum has recently been produced in the Cornell 
Medical School by the injection into rabbits of human thyroids affected 
with Graves's disease. 

The parathyroid glands, 2 which were discovered by Sandstroem, 
are four in number and are histologically different from the thyroid. 
They are usually unaffected by changes in the thyroid, colloid material 
being only rarely present. The superior parathyroids are situated 
behind the junction of the upper two-thirds with the lower one-third 
of the posterior thyroid body and near the cricoid cartilages. The 
inferior group is posterior to the lower part of the thyroid lobes. 
The parathyroids probably develop from the third and fourth branchial 
clefts, those from the lower cleft eventually becoming the higher ones. 
They are of epithelial structure and furnish an internal secretion. They 
possess duct-like passages, probably analogous to the thyroglossal duct, 
and often become cystic. The parathyroids bear a distinct relation to 
the larger thyroid vessels and their shape varies considerably. As age 
advances the amount of fibrous tissue and fat increases. The vessels 
enter at a slight depression which may be regarded as a hilum. Tumors 
sometimes develop in the parathyroids, and their removal may give 
rise to symptoms of myxcedema. Graves's disease is probably due to 
partial aparathyroidism, notwithstanding the fact that the disease is 
benefited by section of the cervical sympathetics. 

1 Pick, Berl. klin. Wchnschr., November 13 and 20, 1905. 

2 El policlinic 0, 1902, no. 21, fasc. 3; Ziegler's Beitrage, 1902, vol. xxxi, p. 142; 
Vir chow's Archiv, vol. clxxiv, no. 3. 



TECHNIC OF EXPOSING THE THORACIC CAVITY 



109 



Superficial Examination of the Pleura and Lungs. — The 
appearance and situation of the presenting portions of the lungs 
are now observed (Fig. 72), as when the thorax is opened, the 
normal lung retracts, on account of its own elasticity. This contrac- 
tion of the lung may not occur because of the absence of elasticity; 
presence of emphysema or of pleural adhesions; because the alveoli 
are full of solids or fluids, the result of inflammation; or stenosis of 
the larynx, trachea, etc., may prevent the egress of air. In cases of 
alcoholic intoxication and suffocation the lungs are generally found to 
be markedly expanded (Orth) . The normal color of the lungs at birth 
is a pinkish white ; in adult life, a dark slate color, mottled in patches ; 
as age advances this mottling may become nearly or quite black, owing 
to the deposit of carbonaceous material. Changes in color may be 
due to differences in the amount and character of the blood present or 
to some pathologic process, as white in the pneumonia of congenital 
syphilis or black in anthracosis. 

Next note the condition of the parietal pleura and the amount of 
fluid contained in the pleural cavity ; whether or not the latter is clear, 
bloody, turbid, or of an inflammatory nature; and whether or not 
adhesions are present. Bread-and-butter pleurisy, etc., may be found. 
The remarks made upon the peritoneal fluid apply with equal force 
to that found here and in the pericardium. As a practical point it 
is well to remember that serous membranes when normal are barely 
visible to the naked eye, being smooth and glistening, but when 
inflamed their appearance depends upon the nature of the inflamma- 
tion; the membrane will then be found roughened and more or less 
opaque, especially if examined by an oblique light. The situation and 
extent of any lesion present should be noted. 

If for any reason a pneumothorax be suspected, after carefully 
removing the fluid present fill the pleural cavity with water and 
inflate the lungs with air by means of an intubation tube connected 
with a pump by a piece of rubber tubing. The rising air bubbles will 
reveal the situation of the laceration in the lung. In examining the 
pleural cavities inspect the left one first. 

Pericardium. — Note the position and condition of the pericar- 
dium, whether or not it is distended with fluid and to what extent it 
is covered by the lungs. When there is much distention of the peri- 
cardial sac, the direction and length of its principal diameters and 
borders — the latter, it should be remembered, are anatomically the 



IIO POST-MORTEM EXAMINATIONS 

reverse of those of the heart — should be noted before any fluid is 
allowed to escape. To open the pericardium it should be grasped 
near its centre by the fingers or a tenaculum, and a longitudinal fold 
elevated before it is incised in order to prevent injury to the heart 
and the escape of any excess of fluid which may be present. A small 
incision is then made at the highest point, under strict precautions if 
a bacteriologic examination is to be made, and the fluid present drawn 
off with a syringe or pipette into a graduated glass and its quantity 
noted. The opening in the pericardial sac may now be enlarged suffi- 
ciently to admit two fingers, which are then spread apart, thus ele- 
vating the pericardium and protecting the heart while the pathologist 
cuts between them. With a knife or a pair of scissors two incisions 
are made — one downward and to the right, the other downward and to 
the left — as far as the diaphragmatic attachment. The right flap is 
then drawn strongly forward away from the heart and another cut is 
made in an upward direction to the point where the pericardium is 
reflected around the vessels coming off from the heart ( Fig. 73 ) . The 
phrenic nerves are now plainly seen on the lateral inner surfaces of the 
pericardium and the anterior portion of the heart is exposed to view. 
Adipose tissue may often be found at the point of attachment to the 
diaphragm. 

Now is a favorable time to examine the cardiac plexus and the 
ganglion of Wrisberg; for their situation the reader is referred to 
Fig. 74, which has been drawn from one by Letulle. 

H y drop eric ardiiim. — Normally there are from one to two teaspoon- 
fuls of clear, citron-colored, alkaline fluid in the pericardial cavity, 
which may or may not coagulate spontaneously. In certain renal, 
cardiac, and pulmonary diseases this may be increased to over a gallon, 
the greatest amount being seen in general anasarca. The serosa is 
smooth, glossy, and transparent. Later it may become serofibrinous, 
hemorrhagic, or purulent. 

Hmno pericardium. — The presence of pure blood in the peri- 
cardial sac is usually due to the rupture of an aneurism of the 
heart or of the aorta, to trauma, etc. Under such conditions the 
blood is present in large amounts and is usually clotted. Hemorrhagic 
exudates may be the result of inflammatory diseases, as in cancerous 
and tuberculous pericarditis, of rheumatism, of chronic nephritis, of 
hypertrophy of the heart, of infectious diseases, of poisons, etc. Here 
the blood is small in amount and is derived from the newly formed 




Fig. 73. — Method of opening pericardium. The left hand supports the right flap of the pericardial 
sac, while the knife cuts the pericardium up to its attachment to the great vessels coming off from 
the heart. 





p. n 


...*■■■ 


^P 



Fig. 74. — a, b, cardiac plexus; c, ganglion of Wrisberg. (After Letulle.) 




Fig. 75. — Pericardium laid open. 



TECHNIC OF EXPOSING THE THORACIC CAVITY IXI 

vessels in the inflammatory tissue. The red tint due to the dissolving 
out of the haemoglobin may be distinguished from hemorrhage by the 
absence of red blood-cells in the liquid when examined under the 
microscope. 

Pneumopericardium (Pneumatosis). — The presence of air in the 
pericardial sac is rare and is nearly always caused by perforation from 
without, as in cases of stab-wounds, though it may be due to com- 
munication with the lung, oesophagus, or stomach. Or it may be con- 
sequent upon decomposition, especially of an exudate. Its pathology 
resembles that of pneumothorax. 

Pericarditis. — The pericardium, normally transparent and glisten- 
ing, may lose its lustre, become rough and hypersemic, and be covered 
with a more or less dry fibrinous exudate. When there is but little 
fluid and abundant exudate, the latter is thrown into villoid projections 
by the movements of the heart, and the characteristic buttered surfaces, 
the hairy heart or cor villosum, may be found. Newly formed granu- 
lation tissue may succeed a fibrinous exudate, with the formation of a 
productive pericarditis and the later plastic adherence of the visceral 
layers of the pericardium, thus causing a complete obliteration of the 
sac. Suppurative pericarditis shows pus in the sac, and may be the 
result of trauma or be secondary to suppurative mediastinitis or 
cancer of the ribs, or it may be an extension of pulmonary or pleural 
affections or a general infection. Minute hemorrhages are seen, with 
flocculent or curdy collections in the dependent parts of the sac, and 
erosions are sometimes present. Organization may take place, vessels 
growing into the exudate from the subpericardium and even from the 
endothelium. This may be followed by calcification or, rarely, by 
osseous formation. In some epidemics of pneumonia I have found 
that pericarditis was the immediate cause of death in nearly all the 
fatal cases. There is also a gonorrhceal variety. Milk spots, the 
result of friction or of old pericarditis, may or may not be elevated. 

Other Lesions. — Cancer, usually secondary, may be met with. In 
a specimen of melanotic sarcoma of the heart and pericardium at the 
laboratory of morbid anatomy in the University of Pennsylvania, the 
lesion was secondary here as well as in the lungs, the diagnosis of 
sarcoma being made by Professor Guiteras from the discovery of pig- 
mented cells in the sputum. Foreign bodies, gummata, cysticerci, 
echinococci, and trichinae have been described. Tubercles may be seen 



II2 POST-MORTEM EXAMINATIONS 

along the course of the vessels, or old cheesy tuberculous deposits may 
be found in chronic cases. 

Injuries. — Wounds of the pericardium and heart may be caused 
by stabs, broken ribs, and foreign bodies in the oesophagus. If the 
main axis of the muscle fibres has been cut, the pericardium will be 
full of blood; if the injury be parallel to its long axis, there may be no 
bleeding and the wound of the heart may heal spontaneously. 
Suturing of the heart muscle is now a well-recognized surgical pro- 
cedure. Foreign bodies, like bullets, have been found encapsulated in 
heart muscle. 

If an aneurism be discovered, it is usually best not to separate 
the aorta from the heart, but to remove the aneurismal sac and the 
heart together. In endocarditis vegetations are sometimes present 
in the arch of the aorta, and might easily be overlooked if not espe- 
cially searched for. To discover air emboli, the pericardial cavity is 
filled with water and the heart opened under water in situ. Gas may 
arise from decomposition of the blood. 

Heart. 1 — The heart is to be observed before it is touched. 
(Fig. 75.) Its normal position may be altered by fluid in the pericar- 
dium or in the pleurae, by cardiac hypertrophy, in which case the apex 
may reach to the anterior axillary line, or by tumors of the medias- 
tinum. Abnormalities in position of the heart caused by peculiarities of 
development may also be found. The heart is about as large as the 
right fist. It measures from base to apex about 3^ inches (from 85 
to 90 millimetres) in men and 3% inches (80 to 85 millimetres) in 
women between the ages of twenty and sixty years ; its greatest trans- 
verse diameter varies from 92 to 105 millimetres in men and 85 to 92 
millimetres in women; it is about 1 34 inches (35 or 36 millimetres) 
thick in men, and from 30 to 35 millimetres in women. Any displace- 
ment is determined by the situation of the apex and the base, which 
are anatomically described especially in relation to the ribs, sternum, 
nipples, and median line of the body. Cardiac enlargement may be due 
to excessive exercise, heart disease, or secondary to disorders of the 
lungs, kidneys, aorta, etc. The color of the surface of the heart depends 
very much upon the condition of the epicardium and the underlying 



1 For a description of cardiac lesions, see Chapter VIII, p. 126 ; of weights and 
measurements, Chapter XXIV, p. 400 ; and of the cardiac vessels in children, 
Chapter XVIII, p. 289. 



TECHNIC OF EXPOSING THE THORACIC CAVITY 



113 



fat. The auricles, especially when well filled, are dark blue, while the 
color of the ventricles differs with the condition of the muscle. The 
consistence of the various portions of the heart depends upon the 
degree of contraction of its muscular tissue, as well as upon the amount 
and composition of its contents (Orth). 

The contraction (systole) and the relaxation (diastole) of the two 
auricles and the two ventricles are considered in relation to the amount 
of blood contained within them. The amount of blood, especially if it 
be fluid, does not afford a criterion of the quantity therein during life, 
owing to the free communication of the vessels and cavities of the 
heart and to post-mortem rigidity of the cardiac muscle. After death 
from asphyxiation the right chambers of the heart are distended with 
dark, fluid blood, while after death from digitalis the left ventricle is 
contracted. Overfilling of the left ventricle is found when death was 
caused by cardiac paralysis. For bacteriologic examination or chemic 
analysis the blood is usually taken with the sterilized pipette, as 
described on page 383, from the cavity which is most distended by 
it, unless, of course, for some reason blood from a special cavity or 
side is desired. The circulation of the lymph and its deposits should 
be carefully studied. 

The epicardium and the amount of subepicardial fat are to be care- 
fully observed for the detection of milk spots and other pathologic 
conditions. In cachexia the subpericardial fat may become mucoid 
and be transformed into a soft, transparent, gelatinous mass, which 
becomes whitish on the addition of acetic acid. Small lipomata may 
be found near the apex. Minute, sometimes confluent, subpericardial 
ecchymoses — the so-called spots of Tardieu — are of medicolegal 
importance, as they are frequent in cases of death due to suffocation, 
particularly in the new-born; but they may occur in the infectious 
fevers, as in diphtheria. 

The situation and condition of the coronary arteries should be 
noted, and they, more especially the anterior one (the left), should 
be palpated, to ascertain whether or not they are " pipe-stem" in 
character. Their interior is to be examined when they are opened 
later on. The coronary veins are easily distinguished from the ar- 
teries by the relative thinness of their walls as well as by their course. 
Overfilling of the larger veins indicates an obstruction to the outflow 
of blood from the right auricle (suffocation, etc.), unless it be confined 
to the posterior parts, in which case it is due to hypostasis. 



II4 POST-MORTEM EXAMINATIONS 

The interior of the heart is now to be examined, and here again, to 
secure the best results, it is expedient to adhere to a definite plan of 
procedure. There are several so-called " methods" of opening the 
heart, but all have the same object and all accomplish it more or less 
completely, — viz., that of exposing the cavities and valves with the 
least possible interference with the septa and the parts subsequently to 
be examined, and in such a way as to permit, as far as possible, 
the component parts of the heart to be reconstructed and returned 
to their original shape and relations. The method adopted and 
described by Virchow for use in the Berlin Charite is undoubtedly the 
best, although the others may, if thoroughly understood and properly 
executed, yield very satisfactory results. 

Ordinarily it is advisable that certain incisions be begun while the 
heart is still in situ and completed after it has been removed from the 
body. As each cavity is opened, careful note should be made of the 
quantity, color, and consistence of the contained blood and of the size 
and character of any clots that may be present. If the opening is 
occupied by a clot, this should be removed. 

Primary Incisions. — After breaking up pericarditic adhesions, if 
present, the heart should be gently rotated towards the right on its 
long axis by slight pressure between the index-finger and thumb of 
the left hand, at the same time that slight traction is made downward 
and to the left of the body. This will bring the points of entrance 
of the superior and inferior venae cavse into view; midway between 
which the first incision is begun and then carried downward in the 
direction of the right ventricular ridge until the right auriculoven- 
tricular septum is reached (Fig. 76, A B, and Fig. 79 1 ). Next malte 
an incision in the right ventricle, just below the auriculoventricular 
septum, passing down the right ventricular ridge to the interventricular 
septum, which is a little to the right of the apex ( Fig. 76, CD). On 
the left side make an incision in the auricle, beginning in or slightly 
below the lowermost pulmonary vein (Fig. 80) and continuing in 
the direction of the left ventricular ridge as far as the auriculoven- 
tricular septum (Fig. 76, E F). Open the left ventricle along the 
entire length of the left ventricular ridge, and, as this ventricle nor- 
mally forms the apex of the heart, the incision will be carried to and 

1 For the sake of clearness, the illustrations show the incision in the heart 
already removed from the body, though the text describes the heart as still attached 
to the body. 



TECHNIC OF EXPOSING THE THORACIC CAVITY 



115 



through that point before the ventricular septum is reached (Fig. 76, 
G H, and Fig. 81). This incision must not join that of the other 
ventricle, but should be separated by an interval of about one-half inch. 
From the fact that these incisions are made while the heart is still in 
the body, they may be called primary incisions. 

In cases of sudden death in which an embolus of the pulmonary 
artery is suspected, it is best to open that blood-vessel before re- 
moving the heart. This assures the finding of the embolus, which 
might otherwise be obscured in cutting the pulmonary artery for re- 
moval of the heart. By this method, also, the ductus arteriosus and 
congenital heart lesions in infants may be investigated. 

Removal of the Heart from the Body. — To remove the heart, 
introduce the index-finger and thumb of the left hand into the left 
and right ventricles, respectively, grasp the ventricular septum near 
the apex, and elevate the heart sufficiently to make slight traction 
on the great blood-vessels (Fig. 82). Then, if no aneurism be pres- 
ent, sever all the normal attachments as near their point of passage 
through the pericardium as possible, and in the following order, — viz., 
the inferior vena cava, the superior vena cava, the pulmonary artery, 
the aorta, and last the pulmonary veins. Or, the heart is drawn 
upward and laterally, first to one side and then to the other, prepara- 
tory to severing the vessels, as may be seen illustrated in Fig. 80. 
Avoid injury to the oesophagus during the removal of the heart from 
the body. The large opening seen in the superior vena cava near its 
termination in the right auricle is the point of entrance of the great 
azygos vein. 

Measuring and Testing the Valves. — Immediately upon the re- 
moval of the heart from the body the blood and clots should be care- 
fully removed from about the valves. The valvular openings are then 
to be measured. Their size is usually estimated by the number of 
fingers that the ostium will admit. Normally the mitral ostium will 
admit the index- and middle fingers, whereas through the tricuspid 
opening the index-, middle, and ring fingers of one hand can be intro- 
duced. This method is, of course, convenient, but is unscientific and in- 
accurate and should be superseded by the use of a constant unit of meas- 
ure. Graduated cones or balls of definite sizes placed on rods (Figs. 50 
and 51) answer the purpose well. They are gently inserted in the 
direction of the blood-current, and the exact size of the opening can 
then be given in millimetres or inches. Vegetations upon the valves 



n6 POST-MORTEM EXAMINATIONS 

may be injured by careless handling. An equally scientific method is 
to measure the attached margins and to determine the diameter in 
terms of a circle by dividing by 3.14 (tc). 

The competency of the valves should now be tested. To do this, 
trim the great vessels down so that the valves may be plainly seen. 
The heart is then evenly supported by each of the vessels in turn, — 
i.e., held in air and in such a way that the semilunar valves will be as 
nearly horizontal as possible, at the same time receiving no unnatural 
support from beneath. Water or mercury is then to be poured in by 
a second person until the vessel is filled, and note is made of the action 
of the valve. If the operator have no assistant present, the heart may 
be immersed in water and then quickly taken out, and the valve being 
tested observed. If there be any leakage from the » aorta, make sure 
that it is not from a cut branch of one of the coronary arteries. The 
best result of the water-test is seen in the semilunar valves, the com- 
petency of the auriculoventricular valves not being accurately deter- 
mined by this method, which has of late rather fallen into disuse. 

Should it be necessary or desirable to ascertain the competency of 
the auriculoventricular valves, the primary incisions above described 
are not made until the heart has been removed from the body, and the 
test is begun by cutting a transverse slice from the apex and exposing 
the ventricles. The heart is now everted and each ventricle is filled 
separately with liquid. This method of removing the organ before 
opening is also useful in examining the heart of a child or when it is 
desired to make a bacteriologic examination of the valves. In the 
latter event no water should previously be used, lest some of the vege- 
tations be washed out or other bacteria than those present be intro- 
duced, thus creating more or less serious confusion. 

Hamilton advises the use of air for testing the competency of the 
valves, and gives the method as follows : 1 "An incision is first made 
into the left auricle, and any post-mortem clots are carefully removed 
from the left chambers through it. Another incision large enough to 
admit the nozzle of a half-inch tube is made into the ventricle near its 
apex and in the line of that required for laying it fully, open. The 
tube is joined to a bellows, and air is driven intermittently into the 
ventricle by means of it, the aorta having been meanwhile closed. The 
valve will be seen to open and close, according as the air is aspirated 

1 Hamilton, Text-book of Pathology, vol. i, p. 9. 




Fig. 79.— Method of opening the right auricle ; an incision is made down to the auriculoventricular 
septum of the right side. This incision is usually made while the heart is in situ, but for the sake of 
clearness is here shown as being made outside of the body. 




Fig. 80.— The pulmonary veins are placed on a stretch and are ready to be incised. There are two veins 
on the right and four on the left side, six in all. 




Fig. 8i. — Method of opening left ventricle. The heart is being opened outside of the body. The left 
hand steadies the heart while the knife cuts along the left ventricular ridge, starting just below the 
auriculoventricular septum and ending at the apex. 




Fig. 82.— Method of removing the heart from the body. The index-finger is placed in the left ven- 
tricle and the thumb in the right ventricle, arid the ventricular septum is grasped. The heart is then 
raised upwards and towards the chin, placing on a stretch the blood-vessels which enter the heart. 
These are cut, starting with the lower pulmonary vein and going from left to right in a circular direction 
until the upper pulmonary veins are reached, or the initial incision may be made at the inferior vena 
cava and end with the pulmonary veins. 




Fig. 83.— The pulmonary artery is made tense with the left hand, while from the centre of the right 
ventricular incision the anterior portion of the right ventricle is cut in the direction of the thumh and 
middle finger which mark the junction of the two anterior pulmonary semilunar cusps. 




Fig. 84.— The left auricle and ventricle are fully opened, exposing the mitral valve, chordae tendinese, 
papillary muscles, endocardium, etc. 




Fig. 85. — Completed incisions of the heart, the organ having been reconstructed after the examina- 
tion of all its cavities and parts. The coronary artery has not been dissected out. This is done for several 
inches with the scissors, and then transverse incisions may be made with the knife about three-eighths of 
an inch apart as the artery becomes smaller and branches. 



TECHNIC OF EXPOSING THE THORACIC CAVITY 117 

or driven out of the bellows. A like procedure is adopted for the dem- 
onstration of the tricuspid. To test the aortic valve, the incision 
before described as necessary to lay open the left ventricle is continued 
up as close to the valve as possible without injuring it. The tube is 
tied into the aorta, and the action of the valve is watched from below. 
The same method is used to test the competency of the pulmonary 
artery valve. As a matter of fact, the tricuspid, in the human heart, 
will always be found more or less incompetent." 

Secondary Incisions. — Place or hold the heart with its posterior 
surface downward. This can be told by the situation of the pulmonary 
artery, which leaves the heart anteriorly. Insert a pair of probe-pointed 
scissors or the blade of the enterotome (now a cardiotonic) into the in- 
cision in the right ventricle, and cut from the centre of that incision 
through the centre of the attachment of the two anterior leaflets of the 
pulmonary artery (Fig. yy, I J, and Fig. 83). The point of junction 
of the anterior leaflets can usually be seen from the outside, but, if not, 
it can very easily be determined by looking into the vessel or feeling it 
with the index-finger. This incision is to be continued until it opens 
up the entire portion of the pulmonary artery which has been removed 
from the body. Some pathologists advise making this incision towards 
the left of the pulmonary artery, so as to cut between the left anterior 
and posterior cusps. The right ventricle is now exposed so that the 
condition of the pulmonary valves, endocardium, myocardium, chordae 
tendineae, etc., of this side of the heart may be noted. Now dissect 
away the connective tissue binding together the pulmonary artery and 
the aorta. 

In opening the left ventricle, cut the anterior wall as near the ven- 
tricular septum as possible, starting from the apical extremity (Fig. 
yy, H) and stopping at the point overlapped by the left auricular 
appendix (K). Then, using the cardiotome, the incision is completed 
(either from the aorta or from the ventricle) by cutting between two 
leaflets (L K). In the aorta there is but one anterior leaflet; conse- 
quently the incision should be to either one or the other side, but 
preferably as close as possible to the curves of the pulmonary artery. 
After examining the valves, myocardium, aortic intima, etc., dissect 
out the coronary arteries with probe-pointed scissors, starting with the 
anterior one at its origin in the aorta just above the semilunar valves. 

Lastly, unite the auricular and the ventricular incisions of each 
side by cutting through the auriculoventricular septa (Fig. yy, B C 



Ug POST-MORTEM EXAMINATIONS 

and F G). The completed lines are shown schematically in Fig. 78. 
In Fig. 84 is shown how well the auricle and ventricle of the left side 
may be examined after the completion of this incision. The knife is 
best introduced from the auricle to the ventricle with the edge of the 
blade down and then turned, the cutting being done from within 
outward. It will be noticed that the instruments are passed through 
the valvular openings in the same direction as the blood flows. The 
valves will not be injured by this method and the entire heart can be 
folded together so as to show its original contour (Fig. 85). In 
extreme mitral stenosis it is often advisable not to complete the left 
auriculoventricular incision. 

In the examination of the auricles an aperture in the foramen 
ovale may be overlooked if the heart be so held as to put the auricular 
wall too much on the stretch. As the communication between the 
auricles usually takes place by openings most frequently coming off 
from beneath the former edges of the valve, all suspicious cracks, ori- 
fices, or slit-like communications should be searched for with a pointed 
probe while the heart is relaxed, care being taken not to tear or puncture 
the tissue or to mistake the ending of the coronary veins, which empty 
near the obliterated opening, for a patulous foramen. In the left auri- 
cle the pulmonary veins rarely come out intact; should they do so, a 
V-shaped incision is made between each pair so as to expose them. The 
"" dog's ears" are opened by cutting towards their tips, with an extra 
incision transverse to this should it be required. Softening clots may 
then be discovered which otherwise would escape attention. The small 
veins of Thebesius empty into the auricles and ventricles. These may 
under certain conditions nourish the heart after infarction of the coro- 
nary artery. 

The situation of the mitral and pulmonary valves can be easily re- 
membered by the mnemonic Martin Luther, The .Reformer, — mitral 
on the /eft side, tricuspid on the right. That there is but one posterior 
cusp to the pulmonary valve and one anterior cusp to the aorta affords 
an easy way to recall this oft-forgotten point. 

A simple method of opening the heart, and one which yields fair 
results, is to place two fingers on the anterior ventricular septum, which 
is recognized by the situation of the anterior coronary artery, and make 
two parallel incisions into each ventricle. The pulmonary artery and 
the aorta may then be opened. 

The heart, freed from blood and clots, is now to be weighed. The 



TECHNIC OF EXPOSING THE THORACIC CAVITY IIOy 

normal heart weighs about 250 grammes in women and about 300 
grammes in men; but when hypertrophied it may weigh over a kilo- 
gramme. In the puerperal state the heart is normally increased in 
size, the right side often dilated (Letulle), the subpericardial fat 
increased, and hemorrhages may occur. 

The gross appearance of the heart, as well as the thickness, color, 
and consistence of the various parts of the cardiac muscle, can now 
be observed. The wall of the right ventricle is normally from 2 to 3 
millimetres thick (in women slightly less than in men) and may 
pathologically measure from 7 to 10 millimetres. The thickness of the 
wall of the left ventricle is from 7 to 10 millimetres, and may be in- 
creased to 25 millimetres or more by pathologic changes. 

The color of the heart muscle varies according to the amount of 
blood it contains, but is always lighter and more grayish red than the 
skeletal muscles. It may be of a brownish red or even brown, as in 
anaemia and brown atrophy of the heart. In the latter condi- 
tion the tortuous vessels and mucoid covering form a striking 
picture. A brown muscle is an atrophic muscle. The scattered 
yellowish patches seen throughout the muscle appear in bands, 
making a sort of net- work (wren's breast or tiger markings). This 
yellow streaking is often most conspicuous on the papillary muscles of 
the left ventricle. When this condition is at all extreme, the endo- 
cardium and pericardium will be found greatly thickened. 1 In septic 
conditions the heart is of a dirty-red color and very friable. Light- 
gray spots or streaks indicate the formation of fibrous tissue. The 
consistence of the heart muscle varies with the color: brown hearts 
are hard and dense, while those of a yellowish tinge are apt to be soft 
and flabby. The fibroid heart is always hypertrophied. After dilata- 
tion of an hypertrophied heart sets in, the muscle becomes softer by the 
process of fatty degeneration. The heart muscle is very soft in sepsis 
and in cases of heart weakness developing after infectious diseases, 
especially after typhoid fever and diphtheria. 

As hypertrophy of the heart may be due to post-mortem contrac- 
tion or to marked systole, this organ should, in some cases, be soaked 
in tepid water before the measurements are taken. The conical shape 
is often lost by the broadening of the apex and deepening of the 
muscles. 

1 E. Beer, Jour, of Path, and Bad., December, 1903. 



I20 POST-MORTEM EXAMINATIONS 

If it be desired to follow out the subclavian vessels by careful dis- 
section, the entire clavicle of that side should first be removed. 

If a sound be used for finding the opening of the thoracic duct into 
the vein, care must be taken not to injure the valve which is present 
at this point. It is much more difficult to find the entrance of the 
lymphatic vein of the right side at the junction of the jugular and the 
right subclavian veins, as the parts are correspondingly smaller on 
this side of the body. 

Removal of the Lungs. — To remove the lung the left hand, palm 
inward, is introduced along the costal curve until the under portion of 
the upper lobe can be elevated without undue pressure being made 
upon the pulmonary tissue. Should there have been no antecedent 
inflammation and consequent adhesions, a condition especially liable to 
be found at the apices, this procedure is readily accomplished, but 
sometimes, when the adhesions are very strong and cannot be broken 
down by the hand, a probe may be used for this purpose, or it may 
be necessary to dissect away the costal pleura and even the ribs and re- 
move them along with the lung. When strong adhesions are found in 
the performance of routine postmortems, the examination of the affected 
lung may be accomplished by making the incisions while the organ is 
still in the body. The upper lobe is now carried away from the median 
line of the body, anteriorly and downward, thus exposing the structures 
forming the root and giving a fine picture of the arch of the aorta. 
Then, separating the index- and middle fingers of the left hand, the 
root of the lung is surrounded so that the upper lobe rests on the palm. 
In this way pressure can be made downward and away from the spinal 
column. Next a perpendicular incision should be made in the direction 
of the spinal column and the bronchus severed. The advantage of 
this procedure is that it enables the operator to observe the character 
of the fluid in the bronchus, avoiding its (otherwise very probable) 
contamination with blood. When the character of the fluid is noted, 
the rest of the structures, including the intercostals arising from the 
aorta, may be severed with a few horizontal incisions, care being taken 
to avoid cutting the aorta, the oesophagus, the large azygos vein, and 
the thoracic duct. It is well to remember when cutting these vessels 
that the left bronchus, which is considerably longer and smaller in 
diameter than the right, is situated below the left pulmonary artery, 
while the right undivided bronchus is entirely above the right pulmo- 
nary artery. The left lung should be removed first, and, as it has 
usually two lobes while the right has three (I have seen this condition 



TECHNIC OF EXPOSING THE THORACIC CAVITY I2 i 

reversed but twice), there is no necessity of adopting any method 
of distinguishing them after they have been removed from the body. 
Then, too, the left lung has a depression in its anterior border for the 
apex of the heart, it is longer and narrower than the right, not quite so 
heavy, and, as already stated, the arrangement of the bronchus and 
artery is different on the two sides. If, however, it is deemed necessary 
to do this, a single cut in the apex or bronchus of the left lung and 
two in the right will afford a ready means of distinguishing the one 
from the other. Normally, the lungs are darkened from inhalation of 
pigmented material, the deposit of pigment often assuming a mosaic 
or net-work appearance, corresponding to the situation of the lym- 
phatics in the external lobules of the lung. Examine the visceral pleura 
for fibrinous deposits, exudates, adhesions, etc. ; note the color, which 
varies with the age, the quantity of contained blood and air, minute 
hemorrhages, excessive pigmentation, cicatrices, spicules of bone, em- 
physematous spots, miliary tubercles, calcified tubercles with cheesy 
interiors, nodules, patches of consolidation, hemorrhagic and anaemic 
infarcts, tumors, infectious granulomata, etc. The lungs should be 
weighed at this time, before they are opened for further study. 

Each lung is then carefully and lightly palpated from above down- 
ward throughout its entire extent by running the fingers over its sur- 
face, the fissures being separated and the anterior and posterior edges 
examined. By gentle pressure between the fingers crepitation is now 
produced. What this is like in the normal lung can be learned only by 
actual trial. In marked emphysema the crackling sound of the larger 
blebs as they break can sometimes be heard across the room. The 
presence of liquid naturally decreases crepitation. In hepatization the 
pulmonary parenchyma may break down even under gentle pressure. 
After squeezing a crepitant portion of the lung, there is ordinarily 
enough air left in the tissues to cause the pieces to float upon water. 
An interesting experiment in cases of atelectasis, infarcts, etc., portions 
for microscopic study having been previously removed, consists in 
blowing air forcibly through the bronchus by means of a cannula con- 
nected with a bellows. 

Placing the lungs upon their posterior surface on a board, rather 
than upon the more slippery stone table, the lower lobe of one lung is 
grasped with the thumb, the remaining fingers seizing the upper lobe ; 1 

1 If the index-finger be introduced into the fissure between the lobes (and this 
method holds the lung very securely), care must be taken not to cut the finger in 
the subsequent procedures. 



t 22 POST-MORTEM EXAMINATIONS 

in this way the organ may be firmly held (Fig. 86). With a single 
stroke an incision should be made from apex to base, commencing at 
the lateral convexity and passing to the entrance of the large vessels 
in the direction of the bronchi, the lung being now laid open like a 
book (Fig. 8j). In the case of the left lung the base had better be 
turned towards the operator, while in the right it will be vice versa, 
requiring an extra incision to open the middle lobe. Immediately note 
the color of the cut surface. The normal color without blood is light 
gray, while with different quantities and qualities of blood the shade 
ranges from light red or brick-red to dark, black, or blue-red. In 
heart disease the color of the pulmonary tissue is apt to be brown ; in 
anthracosis it is black. The amount of hypostatic congestion, and the 
character of the fluid which exudes on lightly squeezing, with the 
fingers, areas not intended for microscopic study, are now determined. 
A microscopic examination of the scrapings collected by passing the 
knife-blade over the cut surface should be made. The appearance of 
the surface after removal of the liquid is determined, and any unusual 
spots more carefully examined. Next it is necessary to examine the 
substance of the lung for cavities, to observe the shape and position 
of areas of consolidation, and to ascertain the specific gravity of con- 
solidated areas in cold water. In pneumonic cases the entire lung may 
be placed in water to determine the portion containing air. A hemor- 
rhagic infarct or a portion of an apoplectic lung will sink in water, as 
well as the lung of croupous pneumonia. Cubes of normal lung may 
sink in fluids having a low specific gravity. 

Examination of the Pulmonary Vessels. — Now is the time 
to open the pulmonary veins (Fig. 88), artery, and bronchi (Fig. 89). 
Parallel or transverse incisions may be made, but care should be taken 
not to make them so deep as to detach any portions of the lung. The 
pulmonary arteries resemble the veins in character, though they are 
thicker, more elastic, and whiter than the latter. By following the 
pulmonary artery up on its anterior aspect from the heart there is no 
danger of mistaking one for the other, this error most often occurring 
when the dissection is not started until after the lungs ,have been 
removed from the body. Again, there is but one artery for each lung, 
while there are two veins. In other words, the two blood-vessels 
which are alike are the veins, and the remaining one is the artery. 

Removal in One Piece and Subsequent Examination of 
Tongue, CEsophagus, Trachea, and Adjacent Structures. — It 
is frequently advisable to excise as one piece the tongue, oesophagus, 




Fig. 86.— Method of opening the left lung. The organ, lying on its posterior surface, is held steady 
by slight pressure with the left hand on its upper portion, while a long, clean cut is made from the apex 
to the base of the lower lobe. In opening the right lung the incision is best made in the opposite direction 
— i.e., from the base to the apex. 





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Fig. 87. — Lung laid open for minute inspection. The lung from this case was emphysematous and 
showed bronchiectasis. Letulle makes seventeen incisions in the lung in its examination. 













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Fig. 88.— Method of opening the branches of the pulmonary vein. The artery is thicker and more 
elastic than the vein. The veins are best opened after the primary incisions shown in Fig. 87 have been 
made. It is naturally impossible in the same lung to make a complete dissection of the bronchi, artery, 
and veins, owing to cutting of vessels not belonging to the system undergoing dissection. 




Fig. 89.— Method of opening the bronchial ramifications. 



TECHNIC OF EXPOSING THE THORACIC CAVITY 



123 



thyroid gland, trachea, epiglottis, etc., so that a minute examination 
of these parts may be made while they are exposed to good light in a 
convenient situation. For this purpose, in those cases where disfigure- 
ment of the body is of no importance, the primary incision over the 
thorax may be extended up to the symphysis menti and the parts 
dissected out with ease. Orth's method of doing this is as follows: 
The skin is first reflected. Then by the use of the cartilage-knife an 
incision is made into the mouth at one angle of the jaws as close as 
possible to the bone, cutting with a sawing motion to the chin and then 
back on the other side to the angle of the jaw, severing the geniohyo- 
glossus muscle. The tongue, after being separated from the jaw, is 
pulled down with the forceps held in the left hand, after which the 
soft palate should be separated from the hard by the use of a knife, 
including in the operation the tonsils. A cut should now be made as 
high up as possible to remove the pharynx, trachea, and cesophagus 
from the spinal column and the deep pharyngeal muscles. This should 
be done with small perpendicular incisions on the spinal column 
through the retropharyngeal and retro-cesophageal tissue, the tongue 
being pulled strongly forward. The parts may now be left intact for 
later dissection, or the cesophagus may be cut off just above its entrance 
into the stomach and the trachea below the vocal cords. These parts 
may be removed in a single piece, however, without the incision being 
extended to the chin, as by careful manipulation the hand can tear 
the skin away anteriorly from its attachments by working from 
beneath, and a knife may be introduced from below into the centre 
of the tongue (through the geniohyoglossus muscle) posterior to its 
frsenum, thus leaving the tip in situ in case an examination of the 
mouth is to be made. (Fig. 90.) By a circular incision of the muscles, 
fasciae, etc., with the knife beneath the skin, keeping as close as pos- 
sible to the bony walls of the jaw, to the carotids, and to the bodies 
of the vertebrae, the pharynx, larynx, trachea, and cesophagus may be 
separated, drawn forward and downward, and removed. The tonsils 
are either torn out bodily with the fingers from below, or else incised 
while in the body and examined from above or below by reflected 
light. The velum palati may also be removed by cutting the hard 
palate in front and dissecting it away from its bony attachment. This 
should always be done in cleft palate. The edges of the tongue may 
be examined for injuries, such as wounds made by the teeth during 
a fatal convulsion. The mucous membrane is flattened in syphilis, 
and the tongue may be the seat of lymphangioma. The vessels of 



124 POST-MORTEM EXAMINATIONS 

the arm should now be cut and the arch of the aorta detached from 
the oesophagus and bronchi. The whole aorta may be examined later, 
if it is deemed better, or this vessel as far as the diaphragm can be 
removed with the oesophagus. This procedure is particularly useful 
when disease of the latter is suspected, as a cancer of the gullet may 
rupture into the aorta or an aneurism of the aorta break into the 
oesophagus. The aorta is from seven to eight centimetres in diameter 
at its commencement and gradually narrows to forty-five or even 
thirty-five millimetres in the abdominal cavity. The oesophagus and 
the trachea are preferably opened up posteriorly throughout their 
entire extent. (Figs. 91, 92, and 93.) Carefully examine the vocal 
cords; see if there are any tumors, syphilitic or tuberculous ulcera- 
tions, inflammation, malformations, foreign bodies, diphtheritic mem- 
brane, etc. The condition of the mucous membrane of the trachea and 
the elasticity of its cartilages should be carefully tested. I have seen 
the whole transformed into a rigid tube by infiltration with lime salts. 
The trachea and larynx may show abrasions and injuries, as by cut 
throat, deformities, stenosis, pressure defects, etc. The oesophageal 
veins frequently carry on a large part of the collateral circulation in 
cirrhosis of the liver, and the rupture of one of them may cause death 
from hemorrhage, much blood being found in the intestinal tract. The 
oesophagus may show peptic or typhoid ulcers, and diverticula of 
various kinds and degrees are seen. The oesophagus may be so dilated 
as to hold several pints of water. Ulcerations on healing may result 
in stricture, which as time goes on may be the starting-point of a 
cancer, as in one of my cases where a stricture due to the taking of 
lye was followed by a squamous epithelioma. Various other forms of 
tumors, as papillomatous outgrowths, occur, and thrush is also found. 

In cases of strangulation, as by hanging or otherwise, the examina- 
tion of the vessels of the neck is of great importance. For this purpose 
the incision behind the ear, made for the removal of the brain, may 
be extended down the neck, and the skin, fat, and superficial fascia 
of the face dissected away, thus making easy the exposure of the 
jugulars, carotids, etc. The tearing of the intima of the carotid indi- 
cates hanging or strangulation; marks produced by pressure of the 
rope, in the form of parchment-like skin at the sides of the neck and 
hemorrhages into the tissues, are also found after death by hanging. 
Emboli of the carotid may cause sudden death, and thrombophlebitis 
of the jugular in cases of thrombosis of the lateral sinus is to be 




Fig. 90. — Method of removing tongue, tonsils, oesophagus, trachea, etc., in a single piece, 
without incising the skin more than is done in the primary cut. 



Palatine arch incised 
Tonsil 



Thyroid gland 

Common carotid artery 
Left subclavian artery 

(Esophagus laid open 



Aorta. 




Palatine arch incised 



Common carotid artery 
Right subclavian artery 



Aorta 

Right bronchus 

Peribronchial lymph glands 



Fig. 91. — Examination of the organs of the neck. The arrows show the direction in which the incisions 
in the tongue and in the posterior wall of the oesophagus are to be made. (After Nauwerck.) 




Fig. 92.— Method of opening trachea posteriorly. The incision starts from above and extends 

downwards. 







Fig. 93.— Examination of trachea and vocal cords. The incision may be made anteriorly, thus 
leaving the walls between the two parts intact. 




Fig. 94.—" Grand swipe" of the thoracic and abdominal organs. 



TECHNIC OF EXPOSING THE THORACIC CAVITY 12 $ 

searched for. Aneurisms are sometimes seen. Hemorrhages into the 
sympathetic nerves may occur in cases of fever with delirium and of 
heat-stroke; pigmentation and fatty changes also take place in the 
cachexias and in fevers. 

The finding of the carotid body is facilitated by the removal of the 
common carotid artery along with about one-half inch of the internal 
and external carotids. The ganglion is located usually at or slightly 
posteriorly to the angle formed by the bifurcation of the carotid, but 
it may be situated at any place in this neighborhood. It closely 
resembles the superior cervical ganglion and is the size of a grain of 
rice, somewhat oval in shape, vascular, and of good consistency. It is 
attached to the artery by means of a small band of connective tissue; 
bands from the capsule divide it into nearly equal parts and again 
into lobules. Funke 1 has tabulated fifteen tumors arising from the 
carotid body, his own case being a perithelioma. Such tumors are 
potato-shaped (Hutchinson, 1888) and may cause death in a year, 
metastases occurring, as to the liver. 

Removal in One Piece of the Thoracic and Abdominal 
Organs. — As was seen on page 17, Letulle advises in the performance of 
an autopsy, the routine removal of the thoracic and abdominal organs 
in one piece. This procedure presents exceptional advantages in the 
case of a child, and the method of its accomplishment is described in 
Chapter XVIII. Fig. 94 shows the method of pulling down the tho- 
racic organs, their attachment to the vertebral column having been 
previously loosened with a knife. Should it be so desired, the tongue, 
oesophagus, trachea, and adjacent structures may be left attached to 
the thoracic organs and removed at the same time. 

1 Amer. Med., July 16, 1904. 



CHAPTER VIII 

DISEASES OF THE HEART, BLOOD, BLOOD-VESSELS, AND 
LYMPH-VESSELS 

Anomalies. — Abnormalities in the development of the heart are 
frequent and varied, occurring especially in non-viable infants. Thus, 
one may find acardia, double hearts, two- or three-chambered hearts, 
rudimentary hearts, malformed blood-vessels, premature closure or 
patency of fetal passages, as of the foramen ovale and ductus arteri- 
osus, imperfections of the septa, increase or decrease in the number 
of semilunar leaflets, stenosis and atresia of the pulmonary, aortic, and 
arteriosal conuses, transposition of the primary arterial trunks, ectopia, 
with deformity of the anterior part of the chest, etc. Dextrocardia 
may be part of a general congenital situs inversus or be confined to 
the thoracic organs alone. Acquired malformations are considered 
under the separate diseases of the heart. 

Blood. — Many of the changes which the blood undergoes are 
macroscopic and can be studied post mortem, though it should be 
remembered that numerous factors tend to alter its composition and 
color in a dead body. A pocket spectroscope and a Tallqvist or a 
Wetherill (Plate III) haemoglobin scale are useful for studying the 
characteristics of the blood. Reproductions of the spectra of haemo- 
globin, reduced haemoglobin, carbon-monoxid haemoglobin, etc., will 
be found in many of the works on physiology and toxicology. In 
using the Tallqvist blood-color scale due allowance must be made 
for the difference in the color of the blood after death and for the 
abstraction of the water. At my request, Dr. Wetherill prepared the 
post-mortem color scale found on the inside of the back cover and 
which shows the approximate percentage of haemoglobin in the blood 
twenty-four hours after death. 1 The method of using the scale is quite 
simple. A drop of blood taken from one of the large veins,' such as an 

1 The writer is at present engaged upon the preparation of a scale designed to 
show the changes of color in human blood twenty-four hours after death resulting 
from the more common poisons. He will be thankful to receive from the reader 
reproductions showing any such alterations except those induced by hydrocyanic acid 
and illuminating gas. 
126 



BLOOD l2 y 

innominate, or from the right side of the heart, is placed upon or 
absorbed by a small piece of filter-paper or white blotting-paper and 
held in the centre of the disk, so as to compare the color with the scale 
in daylight at an angle (by preference) of 45 degrees. As soon as the 
colors are nearly matched, the paper is run out along the black dividing 
line, thus affording an opportunity of forming an intermediary judg- 
ment, which can be approximately determined to within 2.5 per cent. 
The black lines separating the colors and the outer white paper best 
bring out by contrast the various shades of color. 

While printing this scale, the opportunity was afforded of supplying 
a copy of Dr. Wetherill's moisture scale, which is naturally of more 
use clinically than at the postmortem. The change in color depends 
upon the action of moisture on pieces of filter-paper soaked in a 
four-tenths of one per cent, saturated solution of chlorid of cobalt. To 
measure the moisture in a room or upon the surface of a dead or 
living body, the disks are dried over a burning match or in a desiccator 
and placed under celluloid or glass to exclude the atmospheric con- 
ditions, if the latter procedures be desired. After ten minutes a com- 
parison is made with the scale and the percentage determined. In 
uraemia and diabetes the skin is dryer, as well as upon the side af- 
fected by a recent paralytic stroke. The scale may be used for de- 
termining the amount of moisture in the air at the place where the 
body is found or the autopsy performed. 

The specific gravity of the blood is best obtained with the specific- 
gravity bottle, there being no difficulty here, as during life, in securing 
the desired quantity of blood. Hammerschlag's method of mixing 
benzol and chloroform of a known specific gravity until a drop of 
blood remains stationary may also be employed. The specific gravity 
of the blood in health is normally from 1.057 to 1-059, an ^ varies 
directly as the amount of the haemoglobin present. In leukaemia the 
specific gravity is high, while after drowning it differs according as 
the person has been drowned in salt or fresh water. The cryoscopic 
index is — 0.57 C, showing but slight variation during health. 1 For 
its use in drowning, see Chapter XXVIII. 

There may be observed at the time of the postmortem all degrees 
of coagulation of the blood, from an almost absolutely fluid condition, 

1 Cattell, International Clinics, April, 1904. Revenstorf (Vjhrschr. f. gericht. 
Med., vol. xxii, 1903) thus determines the length of time which has elapsed since 
death. 



I 2 8 POST-MORTEM EXAMINATIONS 

as in poisoning by hydrocyanic acid, to a hard and dense fibrinous 
clot, — the so-called heart polyp, — which contains almost no red blood- 
corpuscles. The firm, yellowish to olive-tinted, semitransparent 
" chicken-fat" clots, seen so frequently in pneumonia, adhere to the 
walls of the heart, and indicate slow death, with gradual paralysis of 
the heart's action. When all the coagula are rich in fibrin, some acute 
inflammatory process has caused an increase in the leucocytes and 
blood-plaques, the generators of fibrin. In the left auricle they at times 
assume polypoid or spherical shapes, and may even become attached to 
its wall and undergo organization. The ordinary post-mortem coagu- 
lum is the red clot, the so-called currant- jelly clot (cruror), which is 
not attached to the endocardium, though it may adhere to the muscular 
interstices of the heart. The situation of the body after death may 
sometimes be tentatively determined by the formation of the different 
kinds of clot. Thus, should the frontal part of the longitudinal sinus 
contain a mixed clot, and the occipital a cruror, the inference would 
be that the body had remained on its back after death. A thrombus is 
not usually removed by washing, while coagula are. Hyperinosis, 
or increased capability for fibrin formation in the blood, is at 
times met with in certain anaemic affections and infectious diseases. 
Hypinosis, or decreased capability for fibrin formation, occurs in 
leukaemia, hydraemia, certain of the acute exanthemata, hemorrhagic 
diathesis, obstruction of the biliary tract, and in cases of suffocation 
or intoxication with certain poisons, as carbonic acid. Methaemo- 
globin, found in cases of poisoning by chlorates, nitrites, toadstools, 
etc., gives a brownish tinge to the blood. In putrefaction, if the blood 
be left standing, the clear serum separates and leaves a yellowish- 
green sediment. Under the microscope shadows of red cells are seen. 
The blood is normally alkaline, but at the end in Asiatic cholera it may 
be markedly acid or its alkalinity much diminished. We have already 
seen that the organs quickly become acid after death, but their alka- 
linity returns as decomposition sets in. 

The following diseases may be diagnosed by their agglutinative 
reaction: Typhoid fever, paratyphoid, dysentery, Malta- fever, cholera, 
plague (?), tetanus (in the horse, but not in man), psittacosis, tuber- 
culosis (?), and pneumonia. The reaction with the Proteus may be 
used to distinguish between invasion after death and infection during 
life. Auto-agglutination of the erythrocytes has been observed in 
Hanot's hypertrophic cirrhosis. Flexner believes that the liability of 



BLOOD 



129 



the red corpuscles to become agglutinated in the blood-serum is the 
cause of thrombi which so frequently occur in certain of the infectious 
fevers, as typhoid. 

Pathologic Conditions. — (a) Plethora Vera. — A condition in 
which all the elements of the blood are proportionately increased. ( b ) 
Plethora Serosa. — A marked increase in the watery and salty constitu- 
ents, appearing after transfusion, increased ingestion of liquid, acute 
cardiac failure, etc. (c) Hydremia. — Abnormal increase in the watery 
portion of the blood; seen in cardiac, pulmonary, hepatic, and renal 
diseases, (d) Anhydrcemia. — Here there is a concentration of the 
cellular elements of the blood, due to an abstraction of its watery con- 
stituents, the blood becoming thick and even tarry, as in cholera. It is 
seen, at times, after tapping, as for ascites, and in starvation, (e) 
Anemia. — A diminution in the actual amount of the blood {oligemia) 
or in one or more of its essential constituents, as haemoglobin and 
albumin. When the erythrocytes (red blood-cells) are diminished 
relatively or absolutely, there is oligocythemia. Anaemia may be 
local, as in Raynaud's disease and erythromelalgia, or general, as in the 
rupture of an extra-uterine pregnancy. (/) Primary, Essential, Cyto- 
genic, or Idiopathic Anemia. — An anaemia, the cause of which is not 
definitely known, but usually attributed to the blood-making organs, 
and characterized by a disproportionate reduction in the elements of 
the blood, (g) Secondary, Simple, or Symptomatic Anemia. — An 
anaemia due to a definite cause, as from the parasites Anchylostomum 
duodenale, Anguillula stercoralis, Bothriocephalus lotus, Ascaris lum- 
bricoides, Tricocephalus dispar, and Trichine, or from infectious 
fevers, as diphtheria, toxic agents, as lead and arsenic, etc., and char- 
acterized by a proportionate reduction of the erythrocytes. (h) 
Polycythemia rubra is an absolute increase in the red cells; seen in 
cured cases of anaemia, — usually associated with engorged organs, — 
in new-born children, and in persons living at high altitudes or suffer- 
ing from chronic phosphorus and carbon monoxid poisoning, (i) 
Poikilocytosis. — Bizarre and irregular configurations of the red cor- 
puscles (crenated, reniform, and pyriform are most common) ; seen 
especially in pernicious anaemia. (/) Macrocytosis and Microcytosis. 
— The red cells are respectively increased and diminished in size, (k) 
Crenation. — The haemoglobin is extracted from the corpuscles and their 
subsequent contraction into irregular shapes with serrated edges takes 

9 



^o POST-MORTEM EXAMINATIONS 

place. (/) Laking. — The solution of the haemoglobin in the plasma, 
(w) Hemolysis. — Destruction of red corpuscles; occurs after burns, 
certain poisons, infectious fevers, etc. (n) Cytolysis. — The dissolving 
of cells by poisons, (o) Leucocytosis. — Temporary increase in the 
number of polymorphonuclear neutrophilic elements; marked in the 
new-born, in pregnant and parturient women; usual at postmortem; 
appears with many infections, suppuration, malignant disease, and 
hemorrhage. A leucocytosis of 15,000 per cubic millimetre nearly 
always shows that suppuration is going on in some part of the body. 
(p) Leucopenia. — A diminution in the number of the white blood-cells; 
this condition is to be seen most characteristically in typhoid fever, 
starvation, cancer, influenza, measles, tuberculosis, and Hodgkin's 
disease; normal in pregnancy, obesity, alcoholism, nephritis, icterus, 
typhus, malaria, and cardiac and pancreatic diseases, (q) Lymphocy- 
tosis. — An absolute and relative increase of lymphocytes; commonly 
associated with hereditary syphilis, scurvy, chlorosis, pernicious 
anaemia, Graves's disease, splenic tumors, pertussis, pneumonia, and 
lymphatic leukaemia, (r) Myelocytosis. — An increase in the number 
of myelocytes is always pathologic, and is seen in the greatest degree in 
myelogenous leukaemia, pernicious anaemia, acute infections, as 
typhoid, mania, Graves's disease, syphilis, tuberculosis, osteomalacia, 
etc. It may occur in all diseases with marked anaemia, (s) Eosino- 
philic*. — An increase in the number of eosinophiles ; occurs in asthma, 
fibrinous bronchitis, acute and chronic skin diseases, especially in trich- 
inosis, amoebiasis, and anchylostomiasis ; also after acute infections and 
with malignant tumors (moderate increase). It is a compensatory 
reaction with diseases of the spleen. Eosinophiles are decreased after 
castration, and in the febrile stages of pneumonia, grippe, typhoid, 
diphtheria, and sepsis. The bone-marrow should always be examined, 
as it is from this source that the eosinophiles arise, (t) Lipcemia. — Fat 
globules in the blood, giving it a milky appearance ; seen in leukaemia, 
diabetes, alcoholism, phthisis, etc. (w) Urczmia. — The presence in the 
blood of an excess of chemical compounds, as urea, which should be 
eliminated by the kidneys or other excretory organs. There may have 
been during life an increase in blood-plaques, but they are most difficult 
of demonstration even shortly after death. In uraemia, besides the 
macroscopic lesions of oedema of the brain, a condition of chromatolysis 
of the cells in the central nervous system may be demonstrated. The 



BLOOD 1^1 

destructive changes are especially found in the motor cells, and may 
be followed later on by degeneration of the motor tracts. 1 

Blood-Stains. — When any suspicion of violence arises, look care- 
fully for blood-stains. If in doubt, treat all suspicious findings as if 
they were such, unless some special reason exists for not doing so. 
Such stains should be most critically examined in the privacy of the 
laboratory before expressing an opinion as to whether or not they are 
consistent with human blood. Try to ascertain : ( i ) Their connec- 
tion with the body under examination or with the person suspected 
of the crime. (2) Their extent, using great care in determining the 
nature of the substance stained. (3) Conditions, — whether fluid or 
clotted, wet or dry, cracked or caked, etc. (4) How made, — whether 
by smear, by splash, by flow, by absorption, as in cloths, etc. ( 5 ) Con- 
nect, if possible, the amount, shape, and condition of the stains with 
their probable source, and note any peculiarities. When practicable, 
preserve parts or all of stains. It is often well to saw off an entire 
step or remove a panel of a door in order to produce the same as evi- 
dence in court. In the present state of our knowledge it is not prac- 
ticable to state from what part of the body the blood came and the 
age of the stain, though the more recent the blood the more soluble 
it is said to be. 1 

Two illustrations from my case-book will show the importance 
of this line of research. A man committed rape on a seven-year-old 
child and murdered her. Blood was seen on the fly of his trousers 
by his room-mate. In order to divert suspicion from himself, the 
murderer accused his room-mate of the crime. The trousers of both 
men were sent to me for examination. In the pair of pants belonging 
to the perpetrator of the crime the lining of the fly had been cut away 
and neatly sewed, but there remained a few telltale threads containing 
blood, which was found to possess the characteristics of human blood. 
On the trousers of the other man was found a red substance, which 
examination showed to be lumberman's red chalk, the crime having 
been perpetrated in the backwoods. In the second case blood splashes 
on a white curtain were stated by a murderer to be red paint which 
one of his children had put there with a paint-brush. 

The presence or absence of blood is determined by (1) physi- 
cal examination; (2) chemic tests; (3) spectroscopic examination; (4) 
microscopic examination ; and (5) the hemolytic serum or biologic test. 

1 Editorial, Jr. Amer. Med. Assoc, April 23, 1904. 



1^2 POST-MORTEM EXAMINATIONS 

The diameter of a red corpuscle may be placed at -^Vf of an inch ; 
that of a leucocyte at ^iVo of an inch. Mammals (with the exception 
of the camel, alpaca, and allied species) and cyclostoma among fishes, 
are found with circular red blood-cells. For the first time on record 
Melvin Dresbach, 1 of the Ohio State University, was able systemati- 
cally to study the blood of a healthy mulatto student, from whom about 
ninety per cent, of the red cells taken were elliptic in outline, averaging 
10.3 microns in length and 4.1 microns in width. The cellular consti- 
tuents were normal and no nucleated blood-cells were found. Ehrlich 
and Ewing consider the shape of the cells in this case to be due to a 
congenital condition. 

The agglutinative reaction or antiserum test for the diagnosis 
of human blood has been applied in a number of recent trials. It 
would seem to afford positive proof of the special source of the blood 
under examination, though Robin secured the reaction from the blood 
of a monkey and Linossier, Nuttall, Dieudonne, and others have demon- 
strated the reaction in pus, nasal mucus, saliva, urine, pleural exudate, 
and sweat derived from the human body. Uhlenhuth 2 was put to a 
severe test by the German Department of Justice. Various objects 
stained with the blood of man and of different animals were sent to 
him, the nature of the blood being known to the Department of Justice 
but not to him. When the blood was furnished in sufficient quantities, 
Ihis results in each case were positive. 3 One method of preparing the 
antiserum and applying the test is as follows : Ten cubic centimetres 
of defibrinated human blood, as that freshly obtained from the human 
placenta, are injected into the peritoneal cavity of a rabbit at intervals 
of six days, and after five such injections an effective serum should 
be obtained. Butza 4 prepares the animal by injecting from ten to 
twenty cubic centimetres of a centrifugated human pleural exudate 
intraperitoneally into a rabbit for five or six successive days. The 
animal need not be killed, but bled again and again, as in the prepara- 
tion of the diphtheritic antitoxin. The blood should not be brought 

1 Science, March 18, 1904 ; March 24, 1905. 

* Deutsche med. Wchnschr., September 11 and 18, 1902. 

3 For an account of trial cases see Patek and Bennett, Amer. Med., Septem- 
ber 6, 1902, p. 374; Whittier, Amer. Med., January 18, 1902; Ferrar, Bolletino 
della reale Accad. medica di Genova, 1901, no. 7; Ogier and Stickis, Soc. de 
med. legale, Paris, May, 1901 ; and Bechtel case tried at Allentown, Pa., in 1904. 

4 Spitalul., 1902, vol. xxiii, p. 377. 



BLOOD 133 

to too high a point of efficiency, as it will then require too high a 
dilution for practical purposes. The blood to be tested is diluted with 
water, one to one hundred, and filtered. Of this clear, slightly red 
solution two cubic centimetres are placed in a small tube and mixed 
with an equal quantity of 1.6 per cent, salt solution; six to eight 
drops of the serum of the rabbit are then added to each tube to be 
tested, but all will remain perfectly clear except the tube containing 
human blood. The reaction is extremely delicate and can be obtained 
with very slight traces even of old dried blood. The clouding should 
occur within thirty minutes in the proportion of 1 to 30, and a pre- 
cipitate within two hours; other samples of blood remain clear after 
six hours. The test should always be repeated. Bordet, 1 Deutsch, 2 
Wassermann and Schiitze, 3 and Dieudonne 4 describe practically the 
same method as Uhlenhuth, and have obtained similar results. Bor- 
det and Deutsch each claim to have been the first to use this method. 

Corin 5 believes that the active principle of the serum in the bio- 
logic differential diagnosis of the blood is paraglobulin, for not only 
may blood-serum be used for the purpose, but also transudates con- 
taining globulin. The paraglobulin in an ascitic fluid was precipitated 
by magnesium sulphate, dried, and injected into animals in an aqueous 
solution. In like manner the paraglobulin can be precipitated from 
the blood of the animal experimented upon and preserved in pulver- 
ized form. This powder when wanted for use is dissolved in water 
and employed in testing the blood under examination. Biondi 6 finds 
that the reaction occurs with the semen, so that human and animal 
spermatic fluid can be differentiated. Meyer 7 has even shown that 
Egyptian mummies give this reaction. This test might, for example, 
have been used in the boiled and alkali-eaten bones found in the vat 
in the Luetgert case of Chicago. Evans and Gehrmann 8 have sug- 
gested this test for the purpose of distinguishing horse meat when 
used in sausages. The writer, in the International Medical Magazine, 
March, 1897, an d earlier to his classes at the University of Pennsyl- 

1 Annates de Vlnstitut Pasteur, 1899, pp. 225 and 273. 

2 Orvosik Lapja, 1901, no. 11. 

3 Berl. kiln. Wchnschr., 1901, vol. xxxviii, no. 7, p. 187. 

4 Munch, med. Wchnschr., 1901, vol. xlviii, no. 14. 

6 Vrtljschr. f. gerichtl. Med., 1902. vol. xxiii, p. 61. 

6 Vrtljschr. f. gerichtl. Med., Suppl.-Heft, 1902, vol. xxiii, p. 1. 

7 Munch, med. Wchnschr., April 12, 1904, p. 663. 

8 Amcr. Med., vol. iii, p. 1062. 



I34 POST-MORTEM EXAMINATIONS 

vania, suggested the possibility of the Wiclal test being used in certain 
cases for the identification of human blood. It may be noted that the 
paratyphoid reaction might in certain instances assist in distinguishing 
animal blood. 1 Leblanc 2 and Bonnel have endeavored to identify 
human blood by the form of crystallization assumed by the haemoglo- 
bin, but this method, even should it prove to be an accurate one, re- 
quires a considerable amount of blood. 

Abnormal Constituents of the Blood. — (a) Tumor cells, as in 
neoplasms growing into veins, portions of the valves of the heart 
and of thrombi, fat, as after a fracture, etc. (b) Blackish pigment 
particles, melanaemia, as in malaria, melanosarcoma, and Addison's 
disease, coal dust, often found in the spleen, etc. (c) Hsematoidin 
crystals, (d) Bilirubin crystals in the shape of needles are sometimes 
found microscopically in a clot that has been well washed in water. 
They occur in icterus neonatorum, pernicious anaemia, acute yel- 
low atrophy, pyaemia, etc., but not in ordinary icterus, (e) Bile. 
Gmelin's test for bile may be applied direct to the serum of the blood, 
the bile sometimes imparting to the serum an orange-red tint which 
may be recognized by the naked eye. (/) Glycogen. The glycogenic 
reaction in the blood, first described by Gabritschewski in 1891, is 
determined by placing for one minute a blood smear, face down, upon 
a solution of iodin, iodid of potassium, and gum arabic. If the glyco- 
genic reaction is positive, small or large brownish granules are ob- 
served under the high powers of the microscope in the polynuclear 
leucocytes, or the cells themselves may even assume a diffuse brownish 
color. Some brownish extracellular masses may also be found. The 
reaction is found in suppuration, bacterial infection, uraemia, diabetic 
coma, etc. Locke and Gulland 3 have demonstrated that the reaction 
is always present in an acute attack of appendicitis, and may even 
afford valuable information concerning the severity of the disease. 
Serous pleuritis and simple obstruction of the bowel do not give the 
reaction, (g) Gas bubbles may be due to putrefaction, as air-pro- 
ducing bacteria develop very rapidly after death. In fresh blood air 

1 The Marx-Ehrenrooth test will be found in Munch, tned. Wchnschr., 1904, 
vol. li, no. 16. Deutsch's book is entitled Impfstoffe und Sera, Leipzig, 1903. 
Nuttall's article {Jr. of Hygiene, 1901, vol. i, no. 3) is the best of the early publi- 
cations in English. Uhlenhuth's latest method of differentiating blood from closely- 
related animals is found in the Deutsche med. Wchnschr., 1905, vol. xxxi, no. 42. 

2 These, Paris, 1903. 

* Brit. Med. Jr., April 16, 1904, p. 880. 



BLOOD 135 

bubbles, particularly when in the right heart and surrounded by a clot, 
are due to the entrance of air into the veins during life, (h) Charcot- 
Leyden crystals, seen in leukaemia. (i) Lower organisms, as the 
Spirochete? of relapsing fever (not always found after death), the 
organisms of anthrax, influenza, tetanus, tuberculosis, typhoid fever, 
paratyphoid, Malta fever, glanders, etc., and micro-, strepto-, staphylo-, 
and diplococci, such as the Gonococci and Pneumococci, Plasmodia, 
Filaria sanguinis hominis, Distoma, found especially in the portal and 
splenic veins, Trypanosoma, and many other parasites. Many names 
have been given to those conditions produced by organisms and their 
products acting upon the living tissues of the body: as, septicaemia, 
where there are pyogenic micro-organisms in the blood and tissues, 
without areas of suppuration ; pyaemia, where metastatic absces- 
ses are found in the tissues and organs of the body; and saprae- 
mia, where the symptom-complex is produced by the presence in the 
blood and tissues of the vital chemic products known as toxins. 
These toxins may be formed by the metabolism of pyogenic or sapro- 
phytic micro-organisms. (/) Various vegetable and mineral poisons, 
such as carbon monoxid, hydrocyanic acid, nitrobenzol, etc. 

Blood-Diseases. — Ancemia, Progressive Pernicious. — An idio- 
pathic, chronic anaemia characterized by definite blood-changes, by 
pallor of the mucous membranes, by a lemon-yellow coloration of 
the skin, and by progressively developing weakness without corre- 
sponding emaciation. It is most common in adults of the male sex, 
but may occur in children. Rare cases are seen during pregnancy 
and parturition. It is associated with an extreme anaemia, poor teeth, 
unclean mouth, overwork, and intestinal parasites, especially the Both- 
riocephalus latus and Anchylostoma duodenale. The chief changes 
seen in the blood during life, but which cannot always be demonstrated 
post mortem, are : ( 1 ) Marked reduction in the number of red cor- 
puscles (to one million or less per cubic millimetre). (2) Alteration in 
their shape, — poikilocytosis. (3) Alteration in size, — microcytes, 
macrocytes, megalocytes. (4) Nucleated reds, — normoblasts, megalo- 
blasts. (5) Increase of neutrophilic whites. (6) Haemoglobin markedly 
decreased, but color-index usually high and blood of a raspberry-red 
color. (7) Blood-plates absent or scanty. At the postmortem the 
skin is, as a rule, lemon-yellow in color. The skin and the serous 
membranes commonly reveal hemorrhages, which may, however, be 
present only in the retina. Certain brown discolorations are often 



136 



POST-MORTEM EXAMINATIONS 



found, especially on the abdomen and buttocks. The subcutaneous 
fat is well preserved and of a light-yellow color. The muscles resem- 
ble horse-flesh and are often degenerated. The heart is usually large, 
flabby, empty, intensely fatty, and tawny-brown in color. The other 
organs exhibit fatty changes. The stomach may be normal or the 
disease may be associated with chronic gastritis, gastric carcinoma, 
or atrophy of the gastric tubules. Iron is deposited in excess in the 
lobules of the liver, especially in the outer and middle zones. The 
spleen and haemolymph glands show a marked accumulation of leuco- 
cytes and excess of iron pigment. The spinal cord may show extensive 
posterior sclerosis with hemorrhagic foci, due to the action of the toxins 
and nerve-fibre degeneration. The lesions are usually most marked in 
the part of the tract farthest from the trophic centre. Changes in the 
ganglion-cells of the sympathetic system have been reported. The mar- 
row of the long bones is reddish, resembling that seen in the infant. In 
pernicious anaemia there is incomplete formation of serum. It is stated 
that the clot of pernicious anaemia and that of anaemia secondary to 
cancer may be distinguished by the contraction of the cancer clot and 
the resulting expression of the serum. 

Chlorosis. — Chlorosis is a primary anaemia which occurs usually in 
girls between fifteen and twenty years of age, and is characterized by 
a marked diminution in the percentage of haemoglobin, by alterations 
in the number, shape, and size of the red blood-corpuscles in severe 
cases, and sometimes by hypoplasia of the circulatory and generative 
organs. The white blood-cells rarely show much variation. Cases 
of simple chlorosis rarely come to autopsy. Subcutaneous fat is 
usually well preserved or even increased in amount. The skin is pale 
and of a greenish hue, and other evidences of anaemia may appear. 
Areas of pigmentation, particularly about the joints, occasionally 
occur. The internal organs will be found pale and flabby. The heart, 
large blood-vessels, and generative organs may show insufficient devel- 
opment. (Virchow.) The heart and large veins are often filled with 
a greenish clot. Thrombi, at times multiple, are common, especially 
in the femoral vein and the longitudinal sinus. Pulmonary embolism 
has been observed. 

Leucocythcemia (or Leukcemia) . — A primary anaemia character- 
ized by a great increase in the number of the white corpuscles, by an 
alteration in the relative proportions of the various white corpuscles 
the one to the other, and by marked structural changes in the lymphatic 



BLOOD 



137 



glands, spleen, and bone marrow. It may be (a) splenic, (b) medul- 
lary, (c) lymphatic, or (d) mixed. As a rule, the body is apparently 
well preserved, but in some cases emaciation may be extreme, while 
in others the amount of adipose tissue may be increased and of a 
peculiar punctate appearance, owing to the presence of petechial hem- 
orrhages. The skin is waxy and has a peculiar lemon-yellow color. 
The mucous membranes are blanched and oedema is often present. 
The blood is pale, even grayish, in color, the haemoglobin being often 
reduced one-half or more. It rarely clots with any degree of rapidity, 
and in the clot red cells settle, leaving a white film above. At the 
postmortem the heart and large veins may be found distended with 
large, greenish, pus-like blood clots. In splenic leukaemia microscopic 
examination of the blood shows that the increased white corpuscles 
are largely myelocytes, while in the medullary form they are lympho- 
cytes. The white corpuscles are enormously and permanently in- 
creased, so that one white to twenty red, or even one to one, is not 
uncommonly found. The organs in general are pale; the heart is 
flabby and frequently fatty in appearance. The liver, spleen, and 
lymphatic glands are usually markedly hypertrophied, while the thy- 
roid may be normal or but slightly enlarged. The thymus gland has in 
several instances been found enlarged. Lymphoid masses are seen in 
the lungs. The Peyer patches are often increased in size. 

(a) In splenic leukaemia, which is a comparatively rare form of 
the disease, the spleen is markedly enlarged, somewhat firm in con- 
sistency, and of a reddish-brown color. The capsule is thickened and 
the whole organ is bound down by adhesions. The Malpighian bodies 
are frequently obliterated, their place often being taken by grayish- 
white, circumscribed tumors throughout the organ. The hyperemia 
in some cases is so excessive that rupture of the spleen is said to occur 
from this cause. The vessels at the hilum are enlarged. Dropsy from 
pressure on the abdominal viscera may result. As in other forms of 
leukaemia, the bone marrow may show decided changes, especially in 
the long bones. Instead of fatty tissue there may be splenization, or 
the marrow may resemble the consistency of the matter which forms 
the core of an abscess, (b) Medullary leukaemia very seldom occurs 
as an inflammatory process. Where the marrow changes are excessive, 
the flat bones— as, e.g., the sternum — undergo alterations similar to 
those occurring in the long bones. There is a hyperplasia of the 
red marrow; this may resemble pus or be of a dark-brown color. 



I3 8 POST-MORTEM EXAMINATIONS 

There may be localized swelling of the bone, (c) In lymphatic leu- 
kaemia the lymphatic glands throughout the body, especially those of 
the neck, the axillary and inguinal regions, also the glands of the 
mesentery and the intestines, are swollen, pale in color, firm to the 
touch, but seldom suppurate or show any tendency to run together. 
The spleen, liver, and lymphatic glands, as the tonsils, lymph-follicles 
of the tongue, pharynx, and mouth, often show marked thickening 
of their capsules. On section the glands are somewhat resistant, and 
often exhibit nodule-like bodies, which are firm in consistence and 
largely composed of proliferating leucocytes and connective tissue. The 
liver as well as the spleen is enlarged and may exhibit marked struct- 
ural changes. This form may be associated with, or most difficult 
to differentiate from, lymphosarcoma. 

Von Jaksch's Ancemia. — This is a primary anaemia of infancy, 
closely resembling leukaemia, but without the visceral lesions. The 
red cells are diminished, though many of these are nucleated. The 
spleen, liver, and lymph-nodes are enlarged, and the number of leuco- 
cytes is increased. 

Osier's Disease {Chronic Cyanosis). — A chronic disease of people 
usually past middle life and not associated with dyspnoea, kidney, lung, 
or heart disease, but characterized by marked blueness of the skin. 
There is a marked polycythemia, the red cells varying from 10,000,000 
to 12,000,000 per cubic millimetre and the haemoglobin being increased 
as much as fifty per cent, above the normal. At the postmortem the 
heart and spleen are found enlarged and the internal organs markedly 
congested. At times small hemorrhages are noted. 

Hodgkin's Disease (Pseudoleukcemia; General Lymphadenoma) . 
— A disease characterized by a progressive hyperplasia of the lymph- 
glands, by anaemia, and sometimes by secondary lymphoid growths in 
the liver, spleen, and other organs, but with no severe leucocytosis. 
The lymphatic glands most frequently enlarged are those in the cer- 
vical, axillary, and inguinal regions, though the mediastinal, thoracic, 
and abdominal glands, especially the retroperitoneal, are often affected. 
In the early stages the glands are moderately enlarged, soft- and elastic, 
isolated, and freely movable. Later they increase in size and tend to 
run together, become stony hard, and are surrounded by a dense cap- 
sule. The capsule may perforate, and the growth invade the surround- 
ing structures. On section the tumor appears grayish, white ; it is 
smooth and the interior may be firm and dry or soft and juicy. Sup- 



BLOOD i^g 

puration sometimes occurs when the growth reaches the skin. Ema- 
ciation at the time of death may be extreme. The spleen and liver 
are usually somewhat enlarged, but rarely greatly so, and on section 
show lymphoid tumors varying in size from that of a pea to a walnut. 
The Peyer patches frequently show enlargement. Pleural effusions 
are not uncommon. The skin may be the seat of adenoid growths. 
The glandular enlargements may be due to simple inflammatory hyper- 
plasia, lymphadenoma, or lymphosarcoma. The bone marrow may 
be converted into a rich lymphoid tissue. The blood-changes are those 
of a distinct anaemia of the simple type. The red cells are less numer- 
ous and are slightly smaller; the haemoglobin is always diminished; 
the leucocytes are normal or decreased in number. I have made the 
clinical diagnosis in the case of a Newfoundland dog, confirming the 
diagnosis by microscopic study of the tissues after death. 

Hcemophilia. — An hereditary constitutional disease characterized 
by a marked tendency to excessive hemorrhage from very slight causes. 
It is transmitted through the females of a family to the males. Little 
regarding its morbid anatomy is definitely known, and therefore any 
opportunity for the study of a case post mortem should be taken ad- 
vantage of. The vessel-walls are unusually thin, brittle, narrow in 
calibre, and do not readily contract. In some cases the blood itself 
presents marked alterations. Owing to the ease with which the joints 
are injured, hemorrhages are often found about the capsules of joints, 
with inflammation of the synovial membranes. In a few cases in- 
crease in the number of red cells and diminution of white cells and 
blood-plates have been noted. Geier 1 finds the cytoglobin, which is 
produced by the destruction of the red blood-cells, to be markedly in- 
creased in haemophilia. 

Purpura. — This is characterized by extravasations of blood into 
and from the skin, by great debility, evidences of anaemia, and often 
multiple arthritis. Infectious purpura is seen in pyaemia, septicaemia, 
malignant endocarditis, typhus fever, etc. The forms are (a) pur- 
pura simplex, (b) purpura haemorrhagica, (c) purpura rheumatica, 
(d) iodic purpura, (<?) Henoch's purpura, (/) neurotic purpura, (g) 
mechanical purpura, (A) toxic purpura (seen in snake poisoning, after 
the use of certain medicines, etc.), (i) cachectic purpura. The blood 
clots slowly and imperfectly ; leucocytosis may or may not be present ; 



1 Med. Obozrenije, Mosk., 1904, vol. Ixi, 



I4 POST-MORTEM EXAMINATIONS 

the blood-plates may be scanty; and the red cells are often reduced 
in number. There is a large percentage of lymphocytes and an in- 
crease in the eosinophiles. The skin is dry and pale, except for the 
blotches of extravasated blood, which vary from one to four milli- 
metres in diameter, are bright red in color, later become dark, and 
finally remain as brown stains. The hollow viscera and serous cavities 
may contain considerable quantities of blood-stained serum. The 
serous membranes and solid organs may also reveal hemorrhages vary- 
ing in size from a pin's head to the palm of the hand. Congestion and 
oedema of the lungs are frequently present. There is generally an 
acute diffuse nephritis. Ulcerations of the intestines with enlarge- 
ment of the solitary and agminated glands are sometimes found. In 
one of my cases, in which the purpuric blotches were unusually large 
and widely distributed over the body, a husband was accused of beating 
his wife and thus causing her death. 

Scurvy. — Scurvy is a constitutional disorder characterized by anae- 
mia, great debility, spongy gums, and tendency to hemorrhage. This 
disease is by no means so frequent as formerly, owing to better hy- 
gienic conditions and to the proper feeding of those in ships, prisons, 
work-houses, etc. The blood is dark and fluid; there is a decrease 
in the number of the red cells, many of which are pale and distorted ; 
microcytes are present; there is no leucocytosis. After death decom- 
position sets in rapidly. There is very little wasting of the subcu- 
taneous fat or of the muscles. The hemorrhagic patches observed in 
the skin during life are often obscured by post-mortem lividity ; oedema 
is common. The subcutaneous tissues, especially those of the lower 
extremities, contain a blood-stained fluid, with here and there dis- 
colored patches, some black and others of a pale color. About the 
back of the thigh and knee the muscles and tendons may be embedded 
in a thick, firm clot, and themselves contain numerous hemorrhagic 
foci. Occasional hemorrhages occur within the joints, or into any of 
the serous and mucous membranes or internal organs, especially the 
kidney and bladder. The gums are swollen and may present fungous 
appearances; they are sometimes ulcerated, and the teeth- may have 
fallen out. Rarely there may be ulcers in the intestines. Hemorrhagic 
infarcts are at times seen in the lungs and spleen, the latter organ being 
enlarged and soft, while fatty changes are quite constant in the liver, 
kidneys, and heart. 

Scurvy, Infantile {Barlow's Disease). — Usually associated with 



BLOOD 



141 



improper food, such as too much malted or condensed milk. Cases, 
however, have been reported in breast-fed children. The most im- 
portant lesions are increased vascularity and extravasation of blood 
between the periosteum and the bone and into the cavity of the long 
bones, especially those of the lower limbs, producing tumor-like swell- 
ings. Epiphyseal fractures are not uncommon. In fact, in the major- 
ity of cases there are bone changes analogous to those of rickets, and 
the disease often develops in a rickety child. 1 Deep-seated extravasa- 
tions may give rise to muscular swellings and in some cases to extrava- 
sations in the joints. Smaller extravasations are observed in the 
pleura, lungs, spleen, intestines, and kidneys. The gums are spongy, 
sodden, distended with serum, and sometimes covered with blood. One 
of the most characteristic lesions is extravasation of blood into the 
orbital cavity, causing displacement of the eyeball downward and 
forward. 

Diabetes Insipidus. — A constitutional condition characterized by 
continued secretion of large amounts of pale urine of low specific 
gravity, containing neither albumin nor sugar, attended with excessive 
thirst and at times with emaciation; usually the patient looks well 
nourished. It occurs most often in young males and is usually heredi- 
tary. The urinary system may show merely signs of the passage of 
an abnormal amount of liquid, — enlarged and congested kidneys, di- 
lated pelves, dilated ureters, and an hypertrophied bladder. 

Gout. — A constitutional disease characterized by excessive forma- 
tion of uric acid and the gradual deposition of its salts, especially 
sodium urate, in and around the joints of the extremities, producing 
an acute arthritis. Anatomic changes are found most frequently in 
the great toe, though the disease shows a marked tendency to involve 
the smaller joints, both of the feet and the hands. In acute stages 
there are notable hyperemia and round-celled infiltration and diffusion 
into the joint and swelling of the ligaments. Macroscopically the 
joint is swollen, glazed, tense to the touch, and of a purplish color. 
In the chronic form the ligaments and fibrocartilages of the joint 
become infiltrated with chalky deposits (tophi). These consist of 
sodium urate in the form of crystalline needles or rhombs, which are 
quickly dissolved by hydrochloric acid, but whetstone-shaped crystals 
of uric acid make their appearance. Necrosis in the cartilage always 

1 Lancet, May 3, 1902, p. 1246. 



142 



POST-MORTEM EXAMINATIONS 



precedes the formation of tophi (Ebstein). These deposits may be 
slight or may lead to enormous distortion of the joint. In some cases 
the skin may ulcerate and the tophi be extruded. The deposits may 
be found in the cartilages of the ear, the nose, the eyelids, and occa- 
sionally the larynx. In some cases the synovial fluid contains crystals. 
In chronic cases the joint becomes immovable, due to the exostosis 
and excess of deposits. The kidneys usually show chronic interstitial 
inflammation, with deposits of urates in the form of small flakes or 
stripes, chiefly in the pyramids. Arteriosclerosis, with hypertrophy 
of the left ventricle, is very common. Cutaneous affections, such as 
eczema, are not infrequent. The blood contains an excess of uric acid. 

Varieties of Hemorrhage. — The following terms are applied to 
hemorrhages from various parts of the body: Epistaxis, hemorrhage 
from the nose ; haemoptysis, pulmonary hemorrhage ; haematemesis, or 
gastrorrhagia, hemorrhage from the stomach; enterorrhagia, hemor- 
rhage from the intestine ; metrorrhagia, uterine hemorrhage not occur- 
ring during the regular menses; menorrhagia, excessive menstrual 
flow; post-partum, hemorrhage from uterus after delivery; comple- 
mentary, hemorrhage occurring in some place other than that in which 
the original bleeding occurred ; consecutive or secondary hemorrhage; 
extrameningeal, a hemorrhage external to the cerebrospinal meninges ; 
hemorrhage per diapedesis; hemorrhage per rhexin (diabrosin) ; 
haematometra, collection of blood in the uterus ; hemothorax, collection 
of blood in the thorax; haematuria, hemorrhage from the urinary 
organs ; haemathidrosis, hemorrhage from the sweat-glands ; haemato- 
cele, a collection of blood in the tunica vaginalis testis ; haemopericar- 
dium, a collection of blood in the pericardial sac; purpura, extravasa- 
tion of blood into the skin ; hemorrhagic blebs, blood blisters ; hemor- 
rhagic infarct, a blood clot obstructing a blood-vessel; haematoma, a 
circumscribed collection of escaped blood ; extravasation, the escape of 
blood (extravasat) from the vascular system into the tissues or upon 
the surface ; it is either arterial, venous, capillary, or cardiac ; petechias 
or ecchymoses, small, discrete, punctiform collections of blood, when 
larger and not so sharply defined as suggillations and hemorrhagic 
suffusions. 

Causes of Hemorrhages. — (a) Traumatism, (b) Acute inflam- 
mation, (c) Passive congestion, (d) Corrosive poisons, (e) Malig- 
nant growths, (f) Diseases of the vessels. (g) Rupture of an 



DISEASES OF THE HEART 



143 



aneurism, (h) Cachectic disease, (i) Dyscrasias. (/) Nervous dis- 
turbances, (k) Vicarious menstruation. (/) Toxins. 

Many Coroner's physicians give hemorrhage from the umbilical 
cord as a cause of death in new-born children. Although this fatality 
does occur, it is extremely rare, some obstetricians treating without 
tying the cord hundreds of cases without hemorrhage ; nor is the con- 
dition seen in the lower animals. It is facilitated by cutting the cord 
too close to the abdomen, by forced artificial respiration, and by the 
presence of haemophilia. It may come on several days after birth, and 
at the postmortem the liver appear especially blanched. 

Angina Pectoris. — A symptomatic affection commonly associated 
with more or less myocardial degeneration and occlusion of the coro- 
nary arteries from atheroma and thrombosis. At the autopsy the heart 
is often enlarged and the pulmonary artery and the cavities of the 
heart are filled with post-mortem clots. While aortic and mitral thick- 
enings are usually present, I have examined cases where they were 
absent. The coronary arteries are " pipe-stem" in character, the an- 
terior one being usually most markedly affected. 

Infiltrations and Degenerations. — In fatty infiltration, or 
obesitas cordis, there is an increase of fat in those places where it is 
normally deposited, especially along the grooves of the larger blood- 
vessels. The deposits start from the outside and extend inward along 
the trabecular of connective tissue, while in fatty degeneration the 
changes originate from within. The heart may be embedded within 
such an enormous deposit of fat as to leave no muscle exposed to view. 
Fatty infiltration and degeneration occur most markedly in cases of 
poisoning, as by phosphorus, and the atrophy of the muscle may be 
very extensive. In such cases the heart is so soft that the finger can 
readily be pushed through its walls. Hyaline and amyloid degener- 
ation may also occur. Hyaline degeneration affects tissues protected 
from the atmosphere and not accessible to the organisms of putrefac- 
tion (Flexner). Calcareous infiltration, fragmentation, and segmenta- 
tion may be found. ( See Myocarditis. ) Calcium salts are not deposited 
on a living tissue under normal conditions, except as in formation of 
tears. Muscle-fibres in the heart are united by a cement substance, which, 
if destroyed, produces segmentation; when the fibres themselves are 
broken up we have fragmentation. Both conditions are usually found 
associated. A heart thus affected is easily torn apart by the fingers. 
Brown atrophy is common; the degenerated fibres are dark brown in 



I4 4 POST-MORTEM EXAMINATIONS 

color, contain yellow-brown pigments within the muscle-cells, and the 
cavities are decreased in size. An atrophy of the left ventricle is some- 
times seen in cases of extreme mitral stenosis. Senile atrophy always 
accompanies fibrosis. Fibrosis occurs most often in the aortic valves; 
the corpora Arantii are first affected, later the chordae tendineae become 
thickened, first at the valvular ends. Papillary muscles may also 
become markedly fibroid. ( Osier. ) 

As a result of degeneration spontaneous rupture may occur, usually 
in the anterior wall of the left ventricle. This results from fatty in- 
filtration, degeneration, gumma, or tuberculosis. It has been found 
associated with abscess, aneurism, ulceration, myomalacia, arterio- 
sclerosis, and thrombosis. Fatty degeneration may end in rupture 
(spontaneous) of heart. Rupture may be due to trauma. Blows upon 
the chest may rupture the heart and also cause localized myocarditis, 
injury to mitral leaflets, or tear holes in valves where the chordae ten- 
dineae had been attached. This also occurs from extreme muscular 
action, gunshot wounds, etc. 

Aneurism of the heart itself is usually due to myomalacia, with 
thickening and narrowing of coronary arteries and chronic myocar- 
ditis, often associated with valvulitis, syphilis, etc. It occurs usually 
in the left ventricle near the apex, or may be found in the intraven- 
tricular septum or posteriorly. The endocardium is usually opaque, 
the muscles are sclerotic, and layers of thrombi are found in the sac. 
The aneurism may or may not be lined with endothelial cells. Two 
aneurisms may be found existing in one heart. Now and again an 
aneurism appears on the valves of the heart, and is then spheroid and 
projects from the ventricular face of the semilunar valve. Literature 
is full of reported cases of cardiac and aortic aneurisms, there being 
several pages devoted to this subject in the Index Catalogue of the 
Library of the Surgeon-General of the United States Army. 

Myocarditis. — In the myocardium large hemorrhages may be met 
with, as a result of the rupture of small aneurisms of branches of 
the coronary arteries or as a hemorrhagic infarct. Anaemic infarct 
may also be due to a partially obstructing embolus or the formation 
of a thrombus or to disease of the coronary artery. It usually occurs 
in the left ventricle, at the apex, or in the septum. It is irregularly 
shaped, yellow-white in color, and sometimes turbid or parboiled in 
appearance. This is a common cause of sudden death. Tardieu's 
spots, or small hemorrhages beneath the endocardium and at times 



DISEASES OF THE HEART ^ 

extending into the muscle, are found especially after suffocation and 
in cases of rapid death from acute infectious fevers. Myocarditis 
usually is secondary to inflammation of the heart muscle. Parenchy- 
matous myocarditis may be diffuse or limited. When the inflamma- 
tory process involves all of the musculature of the heart, as is frequent 
in the infectious diseases, it is characterized at first by the flabbiness 
and the turbid grayish-red color of the heart muscle. In the later 
stages there is much fatty degeneration. Segmentary parenchymatous 
myocarditis is marked by a cloudy appearance of the heart muscle, 
which is flabby and friable. (Orth.) Fibres may separate at the 
cement line. Transverse fragmentation of the fibres is the form which 
usually occurs during the death agony. Acute circumscribed intersti- 
tial myocarditis, or abscess of the heart, is usually a part of a general 
pysemic disease, with infection through the coronary circulation. 
These metastatic abscesses occur in cases of puerperal sepsis, with 
osteomyelitis and other intensely septic diseases, but particularly in 
cases of malignant endocarditis. There may be only a few abscesses 
or the heart substance may be studded with innumerable suppurating 
points. In size the abscesses vary from the merest dots to cavities of 
the size of a cherry ; they may perforate or form ulcers in the cardiac 
wall. Acute diffuse interstitial myocarditis occurs in various forms 
of infectious fevers. The affected heart muscle is soft and often dis- 
tinctly friable; there may be spots of hemorrhagic infiltration, but, 
as a rule, the color is rather lighter than that of the normal organ. 
The cavities of the heart are frequently dilated, particularly the left 
ventricle. Chronic interstitial myocarditis or fibrous myocarditis may 
also be diffuse or localized, though the circumscribed form is the most 
common. The process is usually secondary, due to a primary disease 
of the coronary arteries, or to disturbances of the circulation therein, 
consequent perhaps upon old age, intemperance, gout, syphilis, and 
the like. This fibroid overgrowth is very commonly met with at the 
tips of the papillary muscles, on the trabecular, or in the substance of 
the cardiac muscle, and often at the apex of the left ventricle, where 
it may lead to such a degree of atrophy that a chronic localized aneu- 
rism of the heart may be formed by the constant pressure of the blood 
upon this thinned area. The heart is usually hypertrophied and the 
cavities dilated. The characteristic change is the formation of dense, 
grayish sclerotic areas, which appear either as more or less irregular 
spots or as streaks or lines running in the direction of the cardiac 



I4 6 POST-MORTEM EXAMINATIONS 

fibres. The entire substance of the heart may be involved and thick- 
ening of the walls may result. (Stengel.) The condition of soften- 
ing of the organ, or myomalacia cordis, has already been referred to. 
The degenerated tissue may form a scar, but more frequently leads 
to an aneurismal dilatation, which may subsequently rupture. Aneu- 
risms of the sinus of Valsalva may form and rupture in unexpected 
places ; I have seen, for example, an aneurism of an aortic sinus rup- 
ture into the right ventricle. 

Endocarditis. — Disturbances of the circulation of the endocar- 
dium are rare, as this membrane possesses no blood-vessels of its own. 
A diffuse redness in this situation may, however, be the result of 
imbibition, and in the case of long-diseased valves, in which there are 
newly formed blood-vessels, reddish streaks and spots may be ob- 
served, which are due to small hemorrhages. Inflammation of the 
inner lining of the heart is frequently a secondary affection, dependent 
upon inflammatory disorders of other organs, such as suppurating 
wounds, purulent peritonitis, and pneumonia, or to rheumatism, gonor- 
rhoea, chorea, tuberculosis, cancer, etc. The most common organisms 
found are the various forms of cocci. Sometimes, however, the endo- 
carditis is the first local manifestation of an infection, the exciting 
agent of which has left no recognizable traces at the seat of its entrance 
into the body. In the foetus endocarditis is usually situated in the right 
side of the heart, because the blood enters the organ on that side, and 
may be associated with lesions of the ductus Botalli. After birth the 
opposite condition prevails, the lesion being most commonly found 
on the left side. In the great majority of adult patients acute endo- 
carditis affects the endocardium of the valves only, — the mitral, the 
aortic, and the pulmonary valve in order of frequency ; but it is some- 
times found in the endocardium of the cavities of the heart, — in the 
left ventricle, the left auricle, and the right ventricle. Various names 
have been applied to these conditions, as simple, verrucose, benign, 
ulcerative, septic, mycotic, rheumatic, syphilitic, diphtheritic, fibrous, 
or malignant endocarditis. Such cases differ much in their appearance, 
even when produced by the same organisms. Endocarditis starts on 
the endocardium as a minute, roughened area, which is red in color 
and slightly elevated. This can easily be scraped off, but, if the spot 
where it was found is carefully examined with a hand lens, a small 
ulcer will be seen. More and more fibrin is now deposited, and the 
corpuscular elements are caught in its meshes ; the organisms multiply 



DISEASES OF THE HEART 



147 



and the clot undergoes a liquefaction necrosis, the process not stop- 
ping in the newly formed tissue, but often penetrating the valves or 
even the walls of the heart. Embolic occlusion of certain vessels and 
metastatic inflammations in other organs, especially the kidneys, spleen, 
brain, lungs, meninges, and skin, are not infrequently associated with 
endocarditis (Ziegler). Such hemorrhagic areas are to be sought 
for in the palpebral conjunctiva; their discovery therein during the 
external examination of the body has more than once led me to sus- 
pect ulcerative endocarditis, even when there was no clinical history 
of its existence. This previous observation is of special value when 
a bacteriologic examination of the heart is desired. These ulcerative 
areas of valves on healing are replaced by scar tissue, which, by con- 
traction and by various degenerative changes, such as necrosis, fatty 
degeneration, and calcification, give rise to the most fantastic shapes 
and appearances of the parts affected. Old cases are often associated 
with aneurism of the leaflets, dilatation, pouching, or perforation of 
valves. Often small tumor-like masses remain on the leaflets, which 
become thick, rigid, and calcareous. 

Hypertrophy and Dilatation. — These conditions are usually 
associated the one with the other. In hypertrophy the individual 
muscle-fibres are increased both in number and in size, the condition 
being due to too much nourishment or overwork, and may be due to 
intrinsic (cardiac) or extrinsic (extracardiac) causes. In concentric 
hypertrophy the cardiac walls are thickened and the cavities are smaller 
than normal. In simple hypertrophy the overgrowth of the walls is 
associated with normal cavities, while in eccentric hypertrophy dila- 
tation is found along with the thickening of the walls. There may also 
be simple dilatation without hypertrophy. The highest degrees of 
enlargement which I have seen have been found in cases of double 
aortic disease, where, too, moderator bands are sometimes found. It 
would seem that the long-continued administration of digitalis may 
produce hypertrophy. 

Valvular Diseases. — An extreme degree of mitral stenosis is 
seen in the so-called buttonhole mitral, a condition more frequently 
observed in England than it is in this country and which causes hyper- 
trophy and dilatation of the left auricle. Cyanotic induration of other 
viscera, especially of the lungs, and dropsical effusions may follow 
mitral incompetence. In aortic stenosis the valves are usually thick- 
ened, rigid, and cartilaginous; later they become calcified and the 



I4 8 POST-MORTEM EXAMINATIONS 

division between the different cusps is lost. First there is ventricular 
hypertrophy, later right-sided enlargement, and finally dilatation with 
pulmonary congestion. In aortic incompetency arteriosclerotic changes 
are marked, being seen not only in the valves but also in the aorta, and 
associated with dilatation and hypertrophy of the left ventricle and of 
the left auricle, and often followed by fibroid myocarditis. Sudden 
death is frequently due to aortic stenosis, a condition usually associated 
with hypertrophy of the left ventricle and a dilated cavity. The aortic 
ring and segments are atheromatous, puckered, and contracted, often 
calcareous, and may admit only the tip of the little finger. The aorta 
above the stricture is usually dilated. Tricuspid regurgitation is seen 
generally associated with cases of cirrhosis of lung and chronic emphy- 
sema. Cyanosis is common. Pulmonary-valve disease is rare, except 
as a congenital lesion. Stenosis is usually associated with patency of 
the ductus Botalli. 

Syphilis, Tuberculosis, Actinomycosis, Tumors, etc. — Syphi- 
litic gummata appear in the heart as rather large yellow foci sur- 
rounded by fibrous tissue; they may also be found in the arch of the 
aorta. Miliary tubercles, when present, are usually subendocardial 
or situated in the large vessels coming off the heart. At a postmortem 
in Ziegler's mortuary I once saw where caseation of a peribronchial 
gland had extended through the pulmonary artery and given rise to a 
most marked local and general miliary tuberculosis. Actinomycosis 
has been observed. Tumors are rare ; myxomata, lipomata, fibromata, 
fibrous polyps, sarcomata, and rhabdomyomata may be met with as 
primary tumors of the heart, while, as secondary deposits, carcinomata 
and especially multiple melanotic sarcomata may be observed. (Plate 
IV. ) In v. Pessl's case * of extensive lymphosarcomatosis, the heart 
at autopsy showed the anterior wall of the left ventricle and a large 
part of the septum almost converted into a " shell of lime." A car- 
cinoma may thus develop here secondary to one of the penis. 2 Foreign 
bodies, as needles, hat-pins, pieces of bone, etc., have been found in 
the cardiac wall and even in the cavities of the heart. Cysticerci, 
echinococci, and very rarely pentastomata may be discovered in the 
various parts of the heart. 



1 Munch, med. Wchnschr., June 10, 1902, p. 956. 

2 Pepper, Phila. Path. Soc, meeting of November 12, 1903. 



PLATE IV 













m-sZ^w 



>\- 







iftltl 










/apSESB 



&, 






wl 



^ 




fci 






11 



:* ">, 



f^P 



12 



i, fibroma ; 2, chondroma (after Ziegler) ; 3, cavernous angioma of the liver ; 4, myoma ; 5, glioma 
of the brain; 6, giant-celled sarcoma; 7, spindle-celled sarcoma; 8, endothelioma of the pia mater; 
9, adenoma; 10, cancer; n, epithelioma with an epithelial pearl; 12, myxomatous cancer. 



DISEASES OF ARTERIES 149 

Arteries, Morbid Changes in. — Arteriosclerosis. 1 — A chronic 
thickening and hardening, diffuse or circumscribed, of the arteries, 
characterized by a diminution of elasticity of the vessels and marked 
alterations in blood-pressure. The arch of the aorta is the most com- 
mon seat. In the first stage there are a loss of elasticity and some 
dilatation, due to hyaline or other changes in the subendothelial coat, 
and thickening of the intima. The second stage is characterized by a 
thickening of the media, atrophy of the muscular and elastic tissue, 
with proliferative changes in all the coats; the increase of new tissue 
gives rise to pressure on the vasa vasorum, with interference of nutri- 
tion, which leads to the third stage, in which there are more or less 
marked macroscopic changes. New elastic tissue, derived from the 
splitting off of the internal elastic layer of the artery, may be found in 
the intima. The vessels are hardened, firm to the touch, do not retract 
or close when cut, and their lumina may be smaller or larger than 
normal. On the intima may be seen milk-white or yellowish patches, 
containing fat, cholesterin, and detritus, intermingled with calcareous 
plates and areas of ulceration and atheroma. There may be a marked 
tendency to dilatation, with the formation of an aneurism, or to con- 
traction with obliteration. Some cases are associated with fibrosis of the 
aortic valves. As described by Heller, this form when found in the 
thoracic aorta is usually syphilitic. Loss of elasticity may be general 
or local; when permitting more distensibility, we have angiomalacia 
or softening, as in phosphorus poisoning and scarlet fever; if less, 
arteriosclerosis or angiosclerosis, or hardening. An interesting experi- 
ment is to remove the aorta and see how much it will stretch by the 
addition of weights before it ruptures. Special forms. — (a) Senile. To 
a certain degree this may be regarded as physiologic, the elastica being 
developed as in scar tissue. The condition affects the larger arteries 
most ; they are dilated, lengthened, tortuous, thin but stiff ; often show 
atheromatous changes in the intima. Even to the naked eye the suben- 
dothelial tissue is degenerated. Cyanotic induration and senile atrophy 
of the heart, liver, and kidneys are common. Moist gangrene of the ex- 
tremities may follow calcification in the iliac arteries. The changes pro- 
duced by sclerosis of the coronary artery have already been referred to. 
(b) Nodular. Knob-like, flat, yellowish- white projections are seen in 

1 Welch's paper, read at the June, 1904, meeting of the American Medical Asso- 
ciation, should be consulted by those interested in this important subject. 



150 POST-MORTEM EXAMINATIONS 

the aorta and its branches, particularly about the orifices. These in later 
stages undergo liquefaction and form atheromatous ulcers. Dilatation 
or aneurism may then ensue, (c) Diffuse. The lesion is wide-spread 
and more uniform ; the intima, as a rule, does not show marked naked- 
eye changes, though there may be elevated spots of a milk-white 
color. The aorta and its branches are dilated, the branches sometimes 
more than the trunk. Cardiac hypertrophy is constant. The kidneys 
are sclerosed, their capsule is adherent, the cortex irregular and often 
cystic, (d) Endarteritis obliterans. There is particularly a thickening 
of the intima, the entire lumen of the vessel being closed, and is prac- 
tically a compensatory arteriosclerosis. It is not uncommon at the 
base of the brain. Erythromelalgia is largely due to arterioscle- 
rosis. Lead and alcohol are considered to be frequent causes of 
arteriosclerosis. 

Amyloid Degeneration. — Usually microscopic, and best demon- 
strated by staining. Atrophy. — A general diminution in the size of 
arteries, best seen in stumps after operations. Calcareous Infiltration. 
— In the media of the arteries of the old, particularly involving those 
of the extremities, calcification frequently occurs. It interferes with 
the flow of the blood, predisposes to thrombosis, and may be the cause 
of senile gangrene. Seen as a diffuse or circumscribed process, usually 
in connection with atheroma, and as a later stage of fatty degeneration. 
Fatty Degeneration. — In fatty degeneration the affected areas of the 
intima have a white or a citron-yellow appearance. These areas occur in 
the form of points, stripes, and regular or irregular net-shaped figures. 
A frequent location is the posterior wall of the aorta around the origin 
of the intercostals. For more careful macroscopic study the surface 
of the fatty area should be removed with a fine forceps and in the 
centre a shallow incision should be made. Here small and large fat 
droplets can be seen. When placed in Flemming's solution these drop- 
lets become black. The fatty degeneration may involve the media and 
even be the cause of rupture. It is often associated with calcareous de- 
generation. Hyaline Degeneration. — Almost always microscopic; 
affects principally the elastic coat and is often the beginning of an 
arteriosclerosis. It most frequently involves the small arteries. Best 
seen in the glomeruli of the kidney. Hypertrophy. — There is hypertro- 
phy of the muscular layer in some diseases of the kidney, and hypertro- 
phy of this layer in arteries of medium size in aortic insufficiency. A 
general enlargement, best seen in the collateral circulation after ligation 



DISEASES OF ARTERIES i gjj 

of a large vessel. Hypoplasia. — Hypoplasia of the aorta is congenital 
and is the result of stenosis, most commonly situated near the insertion 
of the ductus arteriosus Botalli. It usually soon causes death; if not, 
the aorta is contracted and thinner, but very much more elastic. 
Virchow attributes chlorosis to it. 

Inflammations. — I. Acute endarteritis (proliferative or obstructive 
endarteritis, thrombo-arteritis). This starts with an injury to the 
endothelium, proliferation occurs, and an obstruction is formed in the 
vessel wall, on which a thrombus forms, partially or completely ob- 
structing the vessel. The intima is yellow and may be covered with 
many arcuate limited or confluent ulcers, with a loss of substance. 
Cholesterin and fat cells are found in the detritus. The lesion may 
terminate in absorption, suppuration, ulceration, or fibroid change. II. 
Chronic endarteritis. This usually follows the acute form, but is some- 
times primary. It may be local (organization of a thrombus) ,or gen- 
eral (arteritis deformans) ; when in the media it is known as mesarte- 
ritis and in the adventitia as periarteritis. Thrombosis is more common 
in the veins ; it is usually caused by embolus from the right heart or from 
the left and associated with hemorrhagic infarct. Cases have been re- 
ported of thrombosis in the aorta above its bifurcation, in which the 
aorta and the femoral and popliteal arteries also revealed a marked 
thrombosis. It may occur in a vein during pregnancy, chronic 
nephritis, rheumatism, diphtheria, or typhoid fever. Marantic 
thrombi may form in cases of enfeebled circulation, as in the cachexia 
and anaemia of severe infections, sometimes associated with arteritis 
obliterans. In these cases it occurs usually in the large superficial veins 
of the lower extremities and in the sinuses of the brain. Thrombosis of 
the superior mesenteric artery, with a slate-colored to black gangrene 
of the small intestines for many feet, is sometimes seen. The thrombi 
are gray white, red, or mixed ; if recent, they are attached, of bright- 
yellow color and membranous consistency; if old, they are firmly 
organized and may be calcareous. Thrombus is generally supposed to 
be due primarily to bacteria. The whitish-yellow thrombus is made up 
of platelets, leucocytes, fibrin, and a few red blood-cells, and is 
rich in serum. Thrombi are not at all rare in the heart, occur- 
ring usually in the auricle of the right side or the apices of the ven- 
tricles between the papillary muscles. They often have a root-like 
process, which is especially marked in the appendix, and are most 
frequently found in cases of cardiac aneurism and in endocarditis. 



152 



POST-MORTEM EXAMINATIONS 



Softening by a process of liquefaction necrosis may occur in organized 
thrombi, and autolytic ferments also act. Calcification may take place 
later and vein stones (phleboliths) arise. Arterioliths are shot-like 
bodies, especially found in the arteries of the spleen, bladder, etc. 

Syphilis is usually a diffuse process affecting all the coats, espe- 
cially the intima, and thus giving rise to a local or general sclerosis. 
Gummata are rare. Orth, quoting from Heller, gives the numerous 
small foci of cell-infiltration necrosis, and particularly induration, with 
small thickenings of the inner surface, as the characteristic differences 
between syphilis and chronic aortitis. 

Tuberculosis. — Tuberculous lesions are less common in the arteries 
than in the veins. The small arteries are most frequently affected, as 
those of the pia, the brain, the kidneys, and particularly the lungs. 
The disease starts as a local gray tubercle of hematogenous origin in 
the intima or as an extension from a neighboring tuberculous process. 
Thrombosis and embolism, especially in the brain, are of extreme im- 
portance. In embolism air, fat, portions of tumors, micro-organisms, 
etc., are brought to a smaller vessel from a larger one (though the 
converse may occur), and there set up characteristic changes, as in- 
farcts, softening, abscesses, etc. 

Tumors. — The new growths found in arteritis are angioma, an 
erectile tumor ; capillary naevus, usually found on the face, in which the 
capillaries are dilated and tortuous ; a nsevus composed of dilated and 
tortuous arteries forms a racemose or cirsoid aneurism, which is usually 
found in the subcutaneous tissue. The skin over the tumor is, as a rule, 
very much thinned. An arterial varix consists of a dilatation and 
lengthening of a single artery. Venous nsevus is a tumor made up of 
communicating spaces lined with endothelium into which arteries 
empty and from which veins arise. 

Aneurism. — An aneurism is a circumscribed, tumor-like dilatation 
of a blood-vessel, especially an artery, containing blood in direct con- 
nection with the blood-current. A true aneurism has a sac composed of 
one or more of the arterial coats. A false, spurious, or hernial aneurism 
is one in which some of the walls are formed by the tissues surrounding 
an opening in the artery; these sometimes attain an enormous size. 
The aneurism is called cylindric when the lumen of the artery is sym- 
metrically increased in all directions; saccular when the aneurism is 
sac-like; cirsoid when a large extent, or even the whole ramifica- 
tion, of an artery becomes dilated and tortuous; this form most 



DISEASES OF ARTERIES 



153 



often occurs in the frontal, occipital, or iliac arteries ; fusiform when it 
is spindle-shaped ; sometimes these form near a tear of the intima, the 
media and adventitia becoming markedly sclerosed (arteriosclerotic). 
A traumatic aneurism results from injury or laceration of the intima 
by force. A dissecting aneurism arises when blood circulates between 
the coats of an artery. Extensive degeneration must precede this form. 
I have seen such an aneurism beginning at the transverse arch of the 
aorta and opening again into the blood-stream just above the aortic 
bifurcation. Arteriovenous aneurism arises where there is a communica- 
tion existing between an arterial aneurism and a vein ; a variety of this 
is the varicose, where an artery and a vein communicate through a 
false aneurismal sac lying between them. When bleeding was more fre- 
quently practised than it is now, these aneurisms in the arm were of 
quite common occurrence. In the varicose aneurism there is a com- 
munication between an artery and vein with the interposition of a sac. 
Aneurismal varix is a communication between an artery and a vein 
without the interposition of a sac. Mycotic or infective aneurisms are 
apt to be multiple and are caused by micro-organisms. This variety is 
often seen in connection with malignant endocarditis. The mesenteric 
arteries of the horse sometimes become dilated with considerable num- 
bers of the Strongylus annatus. Miliary aneurisms are usually multiple 
and consist of small dilatations; they are found especially in the brain 
and lungs, and often antedate a hemorrhage in these regions. They 
are best seen in the brain by excising the middle cerebral or basilar 
artery and floating it out in a white dish partially filled with water. 
These aneurisms may be due to emboli. Traction aneurisms have 
been reported by Thoma at the concavity of the arch of the aorta. 
Aneurism by distention, rupture, erosion, and anastomosis, and also 
valvular and congenital aneurisms have been described. Aneurism is 
often associated with arteriosclerosis, embolism, trauma, and infections. 
The change is now believed to start in the elastic coat. 

The walls of the blood-vessels may be present or altogether absent ; 
they may be thickened and opaque or almost transparent. If the aneu- 
rism be large, the cavity has a roughened wall, often lined with endo- 
thelium, and frequently contains clots which are white, red, organized, 
or softening. They often show lamination. I have seen a fibrinous 
clot of an aneurism of the carotid mistaken for a sarcoma of the neck, 
a gluteal aneurism opened for an abscess, and a femoral aneurism 
mistaken for a hernia. Rupture of an aneurism, usually from the 



154 POST-MORTEM EXAMINATIONS 

aorta into the pericardium, is a most frequent cause of deatli in cases 
brought to the notice of the Coroner. The rupture often occurs during 
the act of defecation. Three cases of aneurism of the sinus of Val- 
salva have come under my notice. The direction of the increase in 
size of a forming aneurism depends on its location. Constant pressure 
of the sac may overcome the resistance and cause absorption of the 
densest tissue, even bone. Hence aneurisms of the arch of the aorta 
may rupture externally or erode the vertebral column, even to the spinal 
cord. Life has been prolonged in such cases by wiring and treatment 
with electricity, though the aneurism usually appears in another situa- 
tion. In Stewart's case the patient lived three and a half years, the man 
finally dying from an alcoholic pneumonia. The clot around the gold 
wire may become markedly fibrinous. The danger in the operation 
would seem to be from an embolus. Aneurisms are most common in 
the thoracic aorta, abdominal aorta, cceliac axis, splenic artery, and 
very rare in the hepatic artery. I have seen a few cases of that rather 
rare condition, aneurism of the superior mesenteric artery. 

Congenital aneurism, periarteritis nodosa, closely resembles at times 
sarcoma; nodules may be felt in the abdominal wall, in arteries of 
muscles, and in the viscera. There is marked thickening of the intima 
and infiltration of other coats. 

The question as to the etiology of aneurism is much debated. My 
own statistics on this subject confirm the opinion that syphilis is a fre- 
quent cause, especially in the early stages before marked arteriosclerotic 
changes have taken place in the arteries. This view is also supported 
by the fact that animals are rarely affected with aneurism. The ex- 
perimental production of aneurism in animals by alcohol, trauma, etc., 
affords an interesting field for future investigators. 

Diseases of Veins. — The more common lesions in veins are 
thrombosis and phlebitis. Phlebitis occurs in connection with many 
cases of thrombosis, in gout, and after traumatism; micro-organisms 
are usually found. It appears commonly in sinuses of the brain, asso- 
ciated with leptomeningitis. The intima is rough, uneven, corroded. 
Vein walls are infiltrated and discolored. On the surface over an in- 
fected vein there is a dusky-red line. Thrombosis always occurs. Sup- 
puration or pylephlebitis, associated with thrombosis and with purulent 
softening, occurs in the portal veins. The vein is filled with puriform 
fluid, which may cause a branching abscess all through the liver. A 
varix is a permanent dilatation above a valve, — a long, fusiform dilata- 



DISEASES OF VEINS ^ 

tion (phlebectasia) or cirsoid aneurism. It is most common in the 
leg and is often associated with diseases of the heart, liver, lungs, or 
pleura, or may be caused by the pressure of a tumor. Phlebosclerosis is 
seen at times with dilated veins. The vein in these cases is nearly 
always distorted and thickened. Thrombi often form in dilated parts 
and are sometimes converted into phleboliths. Associated with this 
lesion are oedema, chronic catarrh of a mucous surface, chronic ulcera- 
tion of a cutaneous surface, pigmentation, and productive fibrosis. Cer- 
tain varices have special names, as varicocele, dilatation of spermatic 
veins; hemorrhoids, dilatation of veins of lower rectum; caput Me- 
dusas, dilatation of superficial abdominal vessels, etc. Primary tumors 
are rare in veins. Any tumor may be present secondarily. Often 
there is a fibrous endophlebitis, etc. Syphilitic inflammation is seen 
in portal and other veins and is a congenital form. Tuberculosis of 
a vein from a lymph-node is not uncommon in general miliary 
tuberculosis. 

Chief Lesions Found in Lymph-vessels. — Dilatation is espe- 
cially seen in elephantiasis Arabum and is due largely to Filaricz. Cer- 
tain parts, as the scrotum, labia, and thigh, are generally the seat 
of the lymph stasis. This lesion is always associated with hypertrophy 
and thickening of the tissues. Lymph tumors {lymphangioma) — (i) 
simplex, not much enlarged, (2) cavernosum, much dilated — are 
usually found in the tongue (macroglossia), cheek, etc. Lymphan- 
gioma cysticum occurs most frequently in the neck or the sacral region. 
The contents of the cyst are often very fatty, at times partially coagu- 
lated. Endothelioma and carcinoma may occur. The lesions of 
tuberculosis and syphilis are found. 



CHAPTER IX 

DISEASES OF THE RESPIRATORY TRACT AND ACCESSORY PARTS 1 

Nasal Passages. — Malformations of the nose are very common. 
The entire nose, the septum, or the turbinates may be absent. Devia- 
tion of the septum occurs in about one out of every ten persons. 
Acute Nasal Catarrh (Rhinitis, Coryza). — This condition accompanies 
various infections, as variola, scarlatina, measles, influenza, rotheln, 
and diphtheria. In infants it is often a manifestation of syphilis or 
gonorrhceal infection. The nasal mucous membrane is red, swollen, 
and covered with exudate, the accessory sinus, pharynx, and Eustachian 
tubes being sometimes secondarily inflamed. Empyema of the antrum 
of Highmore may result, but more frequently arises from carious teeth. 
Herpetic eruptions are often seen on the lips. Chronic Nasal Catarrh. 
— Varieties : hypertrophic, atrophic, fibrinous, or membranous. There 
is usually a persistent mucopurulent discharge. In the hypertrophic 
form there are flattening of the nasal bridge, thickening of the alse and 
the mucous membrane, exostoses on the septum, and hypertrophy of 
the cavernous tissue. In the atrophic variety the mucous membrane is 
pale, dry, glazed, and covered with scabs, ulcers, and, at times, necrotic 
tissue, which may lead to perforation of the septum, but this is much 
more commonly seen in syphilitic rhinitis. Adenoids are, as a rule, 
confined to the roof of the nasopharynx, but may occur upon the lateral 
walls. They are smooth, rounded masses, or pedunculated, varying 
in size from a hemp-seed to an almond and of a pale-pink color. These 
may replace entirely the normal pharyngeal tonsil. Nasal tuberculosis, 
especially in the form of lupus, syphilis, glanders, and leprosy, may 
occur in the nose. Rhinoscleroma gives rise to nodular thickenings 
and ulcerations of the tissues of the nose, lips, pharynx, and larynx. 
Tumors. — Fibrous, myxomatous, and cystic growths are by far the 
most common varieties found in the nose, and are most commonly 
situated in the lower third of the chamber. Cysts, fibroma, fibro- 
myxoma, chondroma, osteoma, epithelioma, and angiosarcoma are seen. 
Sarcoma usually affects the nares and ethmoid cells. Carcinoma is 
rare. Rhinoliths are sometimes discovered measuring an inch or more 

1 Based on Allchin's Manual of Medicine, 1902. 
156 



DISEASES OF THE RESPIRATORY TRACT 



157 



in length and nearly as broad. They are quite thin and easily broken 
in their removal. Especially in childhood foreign bodies, such as food, 
coins, seeds, which may sprout, eggs, especially of certain flies, which 
may here assume the larval form, buttons, rags (especially in the new- 
born), blood, vomit, and pus, may be discovered. 

Hay Fever. — An asthmatic disorder manifesting itself by paroxys- 
mal attacks of nasal catarrh with marked periodicity, the attacks being 
induced by certain localities, odors, the pollen of many plants, dust, 
etc. The nasal mucous membrane shows usually some abnormality 
or chronic hypertrophic rhinitis, with free exudation, polyseptal irregu- 
larities, adenoids, and turgescency of the mucous membrane, especially 
over the inferior and middle turbinates. 

Epistaxis. — Bleeding may be due to injury or to acute or chronic 
rhinitis, ulceration of the nasal mucous membrane from tuberculosis, 
syphilis, typhoid fever, diphtheria, or foreign bodies, and is very 
common in malignant new growths and in valvular disease. 

Larynx. — The larynx is frequently deformed from hypoplasia or 
asymmetrical development. The sinus of Morgagni may be dilated 
or there may be fistulous canals from imperfect closure of bronchial 
clefts. Acute catarrhal laryngitis is usually secondary, following in- 
fections, as measles, typhus, smallpox, whooping-cough, etc. The 
vocal cords are reddened, swollen, and covered with viscid mucus. 
In very severe cases erosions and ulcers are observed. Varicose veins 
and punctate hemorrhages are seen, especially in chemic cases. Diph- 
theritic laryngitis is generally a part of a general infection. The 
mucous membrane is covered by a gray-yellow membrane, under which 
the epithelium is eroded and necrotic. Erysipelas also affects the 
larynx. (Edematous laryngitis may be acute or chronic, and is due 
to septic infection, traumatism, certain drugs, or chronic visceral dis- 
eases, — e.g., Bright's disease. This may be inflammatory, non-inflam- 
matory, or dropsical. ( 1 ) The epiglottis, the aryepiglottic folds, and 
the ventricular bands are the parts chiefly affected. The vocal cords 
are seldom included, but the oedema may go below them. The mucous 
membrane is pale, except at the borders of the swelling, which are 
injected. (2) The exudation may be serous, seropurulent, or purulent, 
and may or may not be blood-stained. (3) In very severe cases the 
larynx may be entirely closed, and the mucous membrane swollen and 
reddish purple, the epiglottis appearing as a round, translucent tumor. 
In chronic laryngitis the mucous membranes are reddened, the cords 



158 POST-MORTEM EXAMINATIONS 

are thickened, sometimes with adherent secretion, and the vessels are 
injected. In laryngitis sicca the cords are covered with dry crusts, 
which may be blood-stained. Pachydermia laryngis is a condition in 
which symmetrical fleshy-looking thickenings are found on the cords. 
Singers' nodes resemble these and are round nodules on the upper 
surface and free border of one or both cords. Perichondritis is always 
secondary, the lesion appearing first as a smooth, nodular, unilateral 
swelling, which is soon followed by necrosis or abscess, most often 
involving the cricoid cartilage. It is a common manifestation of 
syphilis or malignant disease. This condition may be followed by 
ankylosis of the crico-arytenoid joint, which is associated with tumefac- 
tion, abnormal position of the arytenoid cartilages, and fixation of the 
vocal cords, or by laryngeal stenosis. The latter is also secondary to 
healing of tuberculous, syphilitic, or chemic ulcers, pressure of foreign 
bodies, etc. In one case a fish-bone was found, transverse in the 
larynx, resting on the ventricular bands and arytenoid cartilages. 

Tumors of the Larynx. — Benign growths are quite frequent. There 
is usually a diffuse hyperemia or a warty or infiltrating growth on one 
cord, situated about the middle and surrounded by a zone of conges- 
tion. Ulceration, perichondritis, and exfoliation of the cartilages are 
common complications. The most common tumors are papilloma, pap- 
illary fibroma, and fibroma tuberosum. The malignant tumors are car- 
cinoma, sarcoma, and epithelioma. Foreign bodies, inducing suffoca- 
tion, are by no means uncommon. I have known a piece of lead-pencil 
and a bolus of food thus to cause death. 

Tonsils. — These glands are inflamed in the course of many in- 
fections and may be primarily affected, as with tuberculosis, gangrene, 
syphilis, and lacunar keratosis. In simple catarrhal inflammations the 
tonsils are uniformly swollen, red, and covered with tenacious mucus. 
In the follicular variety yellow plugs of degenerated epithelium are 
held in the crypts by the swelling of the gland. In the phlegmonous 
form the tonsils may be so swollen that they meet and occlude the 
pharynx and may be yellow from the contained pus. Hypertrophied 
tonsils are manifestations of chronic inflammation, and are often asso- 
ciated with rickets, tuberculosis, adenoids, and chronic nasopharyngeal 
catarrh. There may be a true hypertrophy or overgrowth of but one 
tissue. The follicles may be dilated and filled with cheesy material. 
Sarcoma is a not uncommon tumor. Epithelioma, angioma, fibroma, 
myoma, papilloma, and lymphoma occur. Bone and cartilage are seen. 



DISEASES OF THE RESPIRATORY TRACT 



159 



The Trachea and Bronchi. — Malformations. — Fistula is due to 
imperfect closure of the third and fourth branchial clefts, a small orifice 
remaining, which may communicate with the trachea, or end blindly 
on the anterior edge of the sternomastoid muscle three or four centi- 
metres above the inner end of the clavicle. The inner portion is at 
times dilated, forming a bronchogenic cyst. These are the so-called 
" gill openings" of the human body. 

Asthma. — This condition being due to a spasmodic contraction of 
the bronchial tubes and air-vesicles, the lesions found at the post- 
mortem are not marked, consisting only in hypertrophy and widening 
of the bronchial tubes with thickened mucous membrane and a dila- 
tation of the air-cells, giving the chest a barrel-shaped appearance and 
the dorsal spine a curvature. Pressure on the vagus by enlarged bron- 
chial glands is sometimes the only lesion found, or it may be asso- 
ciated with hypertrophic rhinitis. Charcot-Leyden crystals and Cursch- 
mann's spirals are often discovered in the sputum. 

Bronchiectasis. — There is a local or general dilatation of the bron- 
chial tubes, which may be congenital and unilateral or the result of 
various diseases of the lungs and bronchi. A non-patulous bronchus, 
closed alveoli (atelectatic bronchiectasis), puckering of the peribron- 
chial or interstitial fibrous tissue, parenchymatous changes of chronic 
bronchitis, or the circumscribed narrowing of tumors, etc., sometimes 
produce bronchiectasis. Cylindrical, saccular, spherical, ovoid, fusi- 
form, and moniliform dilatations are seen. At the postmortem large 
sacs may be situated immediately beneath the pleura or a number of 
sacculi varying in size may be found opening one into another. The 
walls are covered with smooth, glistening, or hypertrophied epithelium, 
which may be ulcerated in the dependent portion. Putrefaction (putrid 
bronchitis), fatal gangrene, or a tuberculous lesion may follow the 
retention of the material thus collected. Calcification sometimes occurs. 
The lungs usually show some fibroid change. The air-vesicles are 
emphysematous or condensed by pressure. The liver, spleen, and kid- 
ney often show chronic congestion or lardaceous degeneration. Pleu- 
ritic abscesses, peritonitis, adhesive pericarditis, dilatation of the right 
heart, etc., are complications which are sometimes found to be present 
in bronchiectasis. 

Bronchitis. — Bronchitis is an acute, subacute, or chronic inflam- 
mation of the bronchial tubes, not involving the terminal bronchi, due 
to infection, exposure, irritants, or extension from neighboring organs. 



160 POST-MORTEM EXAMINATIONS 

In acute catarrhal bronchitis the mucous membrane is thickened, 
swollen, at times hemorrhagic, and at first covered with tenacious 
mucus, which later becomes profuse, thin, and purulent, and may fill 
the large bronchi. Lobular atelectasis surrounds the affected areas. 
Suppurative bronchitis results from septic embolism, forming small 
abscesses in the bronchial tubes. Croupous bronchitis is characterized 
by the formation of a diphtheritic membrane, sometimes of complete 
casts of the smaller bronchi, but is not, as a rule, associated with the 
Klebs-Loffler bacillus. Bronchopneumonia, extension to the small 
bronchioles and air-vesicles, oedema, congestion, and local emphysema 
are frequent complications. In chronic hypertrophic bronchitis the 
whole lung is larger, firmer, and darker than normal. The mucous 
membrane is thickened, reddish or slate-gray in color, and often shows 
petechial hemorrhages. The bronchus is sometimes dilated, or is 
thicker and more fibrous, with its lumen narrowed by small, firm, vil- 
lous granulations. This obliterating fibrous inflammation usually 
affects the smaller bronchi and may cause stenosis. The surrounding 
lung is usually emphysematous, pigmented, and shows an increase of 
fibrous tissue. The bronchial glands are enlarged, indurated, and pig- 
mented. Dilatation of the right heart and chronic congestion of the 
liver, spleen, and kidneys are common complications. The lung of 
atrophic bronchitis is smaller and lighter in weight and color. Its 
elasticity is impaired, it feels " cottony" to the touch, and there may 
be increase of connective tissue, the longitudinal bands of elastic tissue 
standing out prominently. The mucous membrane is smooth, atro- 
phied, and the lumen of the tubules may be widened. Putrid bronchi- 
tis is practically a bronchiectasis. The bronchi are dilated ; their walls 
are usually smooth, but are frequently ulcerated. Fatty plugs and puru- 
lent masses such as are found in the sputum during life are seen in the 
ulcers. Purulent oedema of the lung is more or less general. Plastic 
(-fibrous) bronchitis may be regarded as a chronic form of croupous 
bronchitis, occurs only rarely, and is paroxysmal, usually being limited 
to a certain number of bronchi. The membrane is a fibrous, fairly con- 
sistent pseudomembrane about two millimetres thick with no epithelium 
under it. The mucous surface is hypersemic and infiltrated with cells. 
The thick ducts of the glands push the fibrous tissue off and it is 
coughed up. The smaller bronchi show catarrhal inflammation, but 
no membrane. Sometimes coagula are found in the tubes after death. 
Tuberculous bronchitis may be acute, manifesting itself as a part of 



DISEASES OF THE RESPIRATORY TRACT 161 

a diffuse caseous process and involving an entire wall (peribronchitis) 
or appear as tuberculous ulcerations like those of the larynx. Cheesy 
bronchitis is a caseation of retained catarrhal secretion. The mucous 
membrane is infiltrated with cells and these also subsequently caseate. 
Gangrenous bronchitis is associated with bronchiectasis. 

Stenosis of the trachea or bronchi is due to pressure from tumors, 
aneurisms, mediastinal abscesses, hemorrhages, swelling of the lining 
mucous membrane, impacted foreign bodies, etc., to perforating case- 
ous glands or to contraction from syphilitic or tuberculous ulcers. 

Primary tumors of the bronchi are rare. Carcinoma may develop 
from the muciparous glands of the bronchial mucous membrane. Sec- 
ondary tumors are more common. Calcareous, papillomatous excres- 
cences, annular in shape, may be found in the trachea. Foreign bodies 
in the air-passages are discovered usually in the right bronchus. 
If the blocking is partial, vesicular or interstitial emphysema results. 
(Edema, local inflammation, and ulceration of the bronchus, lung, and 
pleura, with rupture of vessels, may occur. 

Diseases of the Mediastinum. — Mediastinitis is rare, and when 
present is generally due to infection by Pneumococci. The cellular 
tissue is infiltrated with a puriform lymph. Pericarditis, pleurisy, ab- 
scess, gangrene, ascites, oedema of the upper part of the body, and 
albuminuria may follow mediastinitis. Mediastinal adenitis may be 
simple, suppurative, or tuberculous. The simple form occurs with any 
inflammation of the neighboring organs. Suppurating glands may 
rupture into the oesophagus, bronchus, or aorta. Tuberculosis of 
glands is usually a secondary involvement from the bones, lungs, or 
pleura. The spindle-celled sarcoma is the most common growth in 
this region. Carcinoma, lymphoma, and lymphosarcoma are also 
found. Dermoid cysts may occur in the anterior mediastinum. 

Goitre. — A local or general hypertrophy of the thyroid gland, 
characterized pathologically by a variety of morbid changes. In the 
same gland may be found cystic disease and mucoid, fatty, gelatinous, 
or colloid degenerations. On section the gland appears as a yellow 
or brownish mass with scattered areas of colloid matter, varying in 
size from a pin-head to a millet-seed. In cystic goitre there is a distinct 
limiting membrane, brownish red if the cyst be due to hemorrhage. 
If slender masses of tissue project from this membrane, the condition 
is known as papillary cystadenoma. In some cases the enlargement 
of the gland may be due to marked vascular dilatation without the 



1 62 POST-MORTEM EXAMINATIONS 

formation of new gland-tissue. If the arteries only are dilated, Orth 
calls it struma aneurysmatica; if 'the veins only, struma varicosa. 
Fibroid or calcareous changes also occur. In fetal adenoma the struct- 
ure maintains its fetal characteristics, — i.e., solid masses or rosettes 
of epithelial cells with little or no colloid material are seen. 

Goitre, Exophthalmic {Basedow's or Graves's Disease). — A dis- 
ease common to women of early adult or middle life, which is char- 
acterized by functional disturbance of the heart; diffuse or unilateral 
hypertrophy of the thyroid gland, rarely as great as in ordinary goitre ; 
a marked increase in the number and size of its blood-vessels ; absorp- 
tion of its colloid material, a replacement of it by a more mucinous 
fluid, and undue prominence of one or both eyes, due to an increase 
of the orbital fat. There is separation of the epithelium lining the 
cavities from the basement membrane, with swelling of the individ- 
ual cells. The thymus gland may persist and undergo' enlarge- 
ment, and there is an increased amount of connective tissue in 
the neck. Marked pigmentation of the skin may simulate Addison's 
disease. Myxcedema may develop in the later stages or the emaciation 
may be extreme. Glycosuria and albuminuria are not infrequent. The 
heart is usually hypertrophied, but may be dilated or normal in size. 

Lungs. — Abscesses. — Abscesses of the lung and neighboring parts 
may arise from pyaemia, embolism, tuberculosis, pneumonia, or the 
presence of foreign bodies, and are due to many varieties of bacteria, 
as Pneumococci, tubercle bacilli, Gonococci, Actinomycetes, the amoebae, 
and various pyogenic micro-organisms. Acute miliary tuberculosis 
without any areas of softening in the lung may be found. An abscess 
may discharge itself through a bronchus or otherwise and leave only a 
dense cicatrix. The solitary abscess is comparatively rare, and usually 
results from disease of the neighboring parts, as the pleura, liver, or 
mediastinum. Such an abscess may become encapsulated and contain 
a greenish-yellow pus of an offensive odor. Multiple abscesses are 
common, generally superficial, frequently wedge-shaped, rarely encap- 
sulated, and vary in size from that of a pea to an orange. They are 
at first firm, grayish red in color, and surrounded by a zone of 
hyperemia. Later they become distinctly purulent, with an irregular, 
ragged cavity. The pleura is usually covered with a greenish lymph 
and may be perforated, causing empyema or pyaemia. 

Atelectasis. — Collapse of the lung, partial or total, may exist in 
the foetus at birth (fetal atelectasis), or be caused by closure of the 



DISEASES OF THE LUNGS 



163 



bronchi (capillary bronchitis), compression from a tumor, hernia of the 
diaphragm, pleuritic transudates and exudates, or marantic conditions. 
The last is due to weakness and is most marked in the smaller ramifi- 
cations of the lower and posterior bronchi, often ending by subsequent 
cedema in pulmonary splenization. The air in the shut-off portion 
is absorbed, and the portion on section is dark red or bluish red and 
firm. In old cases the lungs cannot be inflated, the tissue is dense, 
firm, deeply lobulated, and paler than the rest of the lung. The lung 
is usually atrophied or may be entirely replaced by a fibrous cicatrix. 
When the collapse is superficial, as in rickets or pleurisy, the lung is 
reduced in bulk and wrinkled, fleshy in appearance, smooth, tough and 
inelastic, and dark red in color. If due to bronchial obstruction, scat- 
tered patches of atelectasis occur over the lung, the bronchi leading to 
these areas being filled with mucopurulent secretion. The surrounding 
lung may be cedematous or perhaps the seat of chronic pneumonia. 

Circulatory Disturbances. — Anaemia, hemorrhage, infarcts, fat em- 
bolism, or even air embolism, of the lungs may be associated with a sim- 
ilar condition in the right heart. A number of fatal cases of pulmonary 
embolism have occurred after intramuscular injections of calomel for 
syphilis, caused by detachment of clots from the femoral, iliac, or uterine 
arteries, by hydatids, and by phlebolites. Fat embolism of the lung 
should always be thought of in cases of fractures or of extensive inju- 
ries to the subcutaneous fatty tissues or of traumatic rupture of the liver,, 
from which source parenchymatous emboli may also occur. Haemop- 
tysis may occur from hemorrhagic infarcts, brown induration, tubercu- 
losis, an aneurism rupturing into the trachea or bronchi, acute inflam- 
mations, purpura, scurvy, apoplexy, etc. It is interesting to note that a 
pulmonary hemorrhage in tuberculosis may be the beginning of an at- 
tack or precede a fatal termination. Pulmonary thrombosis may arise 
from embolus, engorgement of the capillaries, or disease of the pulmo- 
nary artery. It is not an infrequent complication in pneumonia and tu- 
mors, and often occurs in cases of atheroma of the pulmonary artery. 
Thrombosis of a pulmonary vein has been reported, usually the result 
of gangrene, pleurisy, or cedema. Hemorrhage into the air-cells and 
lung tissue is due to thrombosis or aneurism of the pulmonary artery, 
or to aspiration, as in gangrene and tuberculosis, or to the hemorrhagic 
diathesis. The extent of lung tissue involved differs very greatly. 
The lung is large, firm, dark, and heavy. On section there is ex- 
travasation of considerable amounts of more or less frothy fluid blood. 



!64 POST-MORTEM EXAMINATIONS 

Passive congestion occurs where there is obstruction of the circu- 
lation, in chronic illness requiring the recumbent position, and in dis- 
eases of the central nervous system. It is basic or hypostatic, (a) 
In mechanical congestion, if the condition has lasted some time, the 
lungs are voluminous, russet-brown in color, cedematous, and cut and 
tear with difficulty, giving rise to the so-called brown induration. On 
section they are of a maroon tinge, which on exposure to the air soon 
gives place to a vivid red. The alveolar capillaries are distended and 
tortuous, the fibrous tissue is increased, and hsematoidin deposits are 
found in the epithelial cells, (b) In hypostatic congestion the bases 
of the lungs are deeply cyanosed and heavy and the posterior parts 
engorged with blood and serum. In some instances portions of the 
tissue will sink in water and on section exude a bloody serum. In pro- 
longed coma the hypostatic congestion may be associated with patches 
of consolidation due to the aspiration of food into the air-passages. 
(c) Passive congestion occurring in cerebral apoplexy is most marked 
in or may even be confined to the paralyzed side. 

Notwithstanding its ample collateral circulation, the lung is fre- 
quently the seat of small or large infarcts, especially of the hemorrhagic 
variety, usually situated peripherally and associated with brown indura- 
tion. They may be single or double. Thrombus, rupture from overdis- 
tention, and infection of an embolus are the most common causes of this 
condition. When recent the infarcts are dark red, firm, resistant, and 
vary in size, sometimes occupying the greater part of a lobe. Slough- 
ing and gangrene may follow. The pleura is congested and covered 
with exudate, the branches of the artery going to the lesion being filled 
with clotted blood. In old cases a pigmented scar may alone show 
the seat of a former infarct. 

Pulmonary oedema, which is a transudation of serum into the al- 
veoli and their walls, may be general or confined to the bases of the 
lungs. The organ is bulky, heavy, and pale, and pits on pressure. In 
some cases there is a partial consolidation, the lung appearing gelat- 
inous and containing less air than normal. On section it exudes a clear, 
frothy serum. The dependent parts may be red in color and boggy. 

Emphysema. — The dilatation of the air-vesicles is due to some 
weakness of the lung structure, as a congenital absence of elastic tissue, 
atrophy of the diaphragm, etc., and a dilating force, usually expiration, 
as chronic cough, certain occupations, etc. It may follow senile changes 
or a traumatism. The thorax is barrel-shaped and increased in its 



DISEASES OF THE LUNGS 165 

anteroposterior diameter. The clavicles, the sternum, and the costal 
cartilages are prominent. The intercostal spaces are enlarged and the 
sternal fossa is deep. The back is rounded and the curve of the spine 
increased. The neck appears to be shortened. Dilated veins may be 
seen along the line of the attachment of the diaphragm. On removing 
the sternum, the anterior mediastinum is found completely occupied 
by pulmonary tissue, the pericardial sac being entirely covered; the 
lungs are large, light in color or only slightly pigmented. They are 
inelastic, do not collapse, but pit readily on pressure. To the touch 
they are soft, like feathers; expulsion of the air causes a crackling 
sound, and a paper-thin tissue remains. The edges are rounded and 
obtuse. Beneath the pleura, especially about the anterior margins 
and the lungs irregular in shape. The right heart is dilated and 
of a delicate bladder-like appearance may be seen, varying in size 
from that of a pea to a hen's egg (bullous emphysema). Amyloid 
bodies are sometimes found loose or embedded in the walls. Local 
emphysema is common around old fibroid or tuberculous lesions, the 
dilatation affecting also the bronchi. In the atrophic form, really a 
senile atrophy, the lungs are small, pale, dry, and pigmented, pit on 
pressure, and collapse when the thorax is opened. The chief seats 
are at the edges and the apices. The mucous membrane of the large 
bronchi may be rough and thickened; bronchiectasis may be present, 
and the inner surface of the lobe near the centre, enlarged air-vesicles 
hypertrophied ; the pulmonary artery is enlarged and atheromatous. 
Emphysema may be vesicular, being confined within the dilated alveo- 
lar spaces, or it may be interstitial, the alveolar walls being broken. 
This is seen especially beneath the visceral pleura and may be pro- 
duced post mortem by decomposition. 

Gangrene (Pneumomalacia) . — Gangrene may be circumscribed 
or diffuse, and affects usually the peripheral portions of the lower 
lobe rather than the central. It is by some supposed to be due to 
a specific bacillus. The gangrenous part is large, firm and solid or 
of a pulpy consistence, heavy, and of an ash-gray to greenish-black 
color. The outer tissues are intensely cedematous, next is an area 
of deep congestion, and then a cavity with shreddy, irregular walls 
containing a greenish fluid of a most offensive odor. The pleura 
may be inflamed and contain an abnormal amount of exudate, or it 
may be perforated, causing a pyopneumothorax. The gangrenous 
material gives rise to an intense bronchitis, the bronchial tubes being 



X 66 POST-MORTEM EXAMINATIONS 

obstructed by a thin, highly offensive pus or by mucus containing 
fatty acids, tyrosin, and leucin. The elastic threads disintegrate later 
than the remaining tissue, a fact of considerable diagnostic value. 
Embolic processes are common, abscesses of the various organs, espe- 
cially the brain, being the result. 

Parasites. — Certain parasites may infest the lungs. The Asper- 
gillus niger and fumigatus are sometimes found in these organs, 
always associated with a pneumomycosis, and the Mucor mucedo, a 
yeast fungus, in cases of cancer. Cysticercus cellulosce, Strongylus, 
and Distoma hcematobium are now and again found. Mackenzie 1 re- 
ports a case in a Japanese from Portland, Oregon, of parasitic haemop- 
tysis or infection with the Distoma Westermanni (D. pulmonale). 

Pneumonia. — The chief forms of pneumonia are catarrhal (bron- 
chopneumonia), chronic interstitial, and lobar (croupous and fibrin- 
ous). In cattle there is also found a very infectious variety known 
as pleuropneumonia. Catarrhal pneumonia is an acute or chronic 
inflammation of the lungs, involving both the bronchial tubes and 
air-vesicles, and due to extension of inflammation from neighboring 
parts, aspiration or inhalation of irritants, or micro-organisms, — e.g., 
Diplococcus pneumonicE, Staphylococci, Streptococci, the diphtheria 
bacillus, and the bacillus of pneumonia, or it may follow as a sequel 
to the infectious fevers. The lung is larger, heavier, and firmer than 
normal, and in my experience the lower lobe of the right lung is most 
frequently affected. On section the surface is somewhat dark red 
in color, distinctly mottled, and may drip blood. On palpation irregu- 
lar nodular areas of gray hepatization can be felt, surrounded by 
crepitant tissue. The nodules, seldom larger than a hazel-nut, con- 
tain a central bronchiole surrounded by a grayish-red elevated area 
of consolidation and filled with tenacious purulent mucus which can 
be pressed out. Recent patches are red-brown in color, firm, smooth 
or finely granular, but later they are gray and soft. Minute hemor- 
rhages are common near the affected areas and on the pleural surfaces. 
The pleura is bluish in color and rough. Emphysema is seen on the 
anterior and upper portions of the lung, especially within the inflamed 
areas. Fibroid changes seldom follow bronchopneumonia. Associ- 
ated with this variety of pneumonia may be found enlarged bronchial 
glands, a dilated right heart, gastritis, enteritis, congestion of the 

1 Jr. Amer. Med. Assoc, April 30, 1904, p. 1133. 



DISEASES OF THE LUNGS 



167 



liver and kidneys, and rarely pericarditis or pulmonary thrombosis. 
Catarrhal pneumonia in itself, except in the very young or the very old, 
is rarely fatal. 

Chronic interstitial pneumonia may be due to acute inflammations 
(rare), tuberculosis, chronic pleurisy, chronic poisoning, or syphilis, 
and is usually unilateral. The chest on the affected side is sunken, 
deformed, and the shoulder depressed, the heart being drawn over 
to the affected side. The opposite lung is usually emphysematous. 
On opening the chest the affected part, more or less deeply pigmented, 
is seen to be almost airless, quite firm, and very resistant to the knife, 
lying back against the spine, and usually held by dense adhesions. 
On section grayish fibroid tissue of variable amount is found, which 
may be more or less dilated. The unaffected lung is much enlarged, 
occupying the greater portion of the mediastinum. The heart is 
hypertrophied and the blood-vessels may be atheromatous. Associ- 
ated lesions are tuberculosis or syphilis, a cavity of the apex, pul- 
monary aneurism, and amyloid disease of the viscera. 

Croupous {lobar) pneumonia is discussed on p. 327. 

TABLE SHOWING DIFFERENCES BETWEEN CROUPOUS AND 
CATARRHAL PNEUMONIA. 

Croupous Pneumonia. Catarrhal Pneumonia. 

1. Whole lobe usually affected; hence 1. Lobules affected; hence the nam* 

the name lobar pneumonia. lobular pneumonia. 

2. No areas of healthy lung tissue in 2. Irregular areas of lung tissue in va 

affected lobe; other lobes healthy, rious stages of degeneration intei 

but may be congested, especially mingled with normal lobules, 

adjacent portions. 

3. Lung weighs much more than nor- 3. Lung weighs but slightly more than 

mal. An entire lobe may sink in normal. An entire lobe will float 

water. on water, though small portions 

may sink. 

4. Microscopic appearance varies ac- 4. Microscope reveals three zones : cen- 

cording to stage. Much fibrin; tral, a small bronchus; middle, a 

hence the name fibrinous pneumo- desquamative area containing many 

nia for this condition. cells, but little or no fibrin; outer, 

a zone of congestion. Hence the 
synonym bronchopneumonia. 

5. An extensive fibrinous exudate on 5. Exudate slight, if present. 

the pleura covering the affected 
area ("bread-and-butter" pleu- 
risy) ; hence the name pleuro- 
pneumonia for this affection. 



1 68 



POST-MORTEM EXAMINATIONS 



TABLE SHOWING DIFFERENCES BETWEEN CROUPOUS AND 
CATARRHAL PNEUMONIA. 



Croupous Pneumonia. 

6. Pneumococcus usually found; Rose- 

now grew it from the circulating 
blood nine times out of ten. 

7. Usually at base and posteriorly. 



8. Usually one-sided. 

9. On section the lung varies according 

to stage, the marbled appearance 
being especially seen in the third 
stage. Notice the fibrinous plugs. 

10. Sputum, — so-called rusty sputum. 

11. Lung lesions of same age. 



12. Experimental production difficult or 
impossible. 



Catarrhal Pneumonia. 
6. Pneumococcus rarely found. 



7. Usually at the termination of the 

smaller bronchioles and anywhere 
in the lung. 

8. Usually on both sides and associated 

with other diseases. 

9. On section the lung is congested. 

Small, angular, irregular patches, 
the central portion being the oldest, 
are seen. 

10. Sputum more purulent. 

11. Diseased portion of the lung varies; 

some spots are old, some are new, 
the oldest being around the bron- 
chioles ; healthy tissue between 
affected areas. Caseous pneumo- 
nia, really a form of catarrhal 
pneumonia, is due to the action of a 
toxin, as from the tubercle bacilli. 
In phthisis there may be small 
areas of croupous pneumonia. 

12. Capillary bronchitis and catarrhal 

pneumonia are, pathologically, 
practically the same. Seen es- 
pecially in the very old and the 
very young. 



Pneumonoconiosis. — This fibroid condition of the lung, often 
associated with tuberculosis, and produced by the inhalation of parti- 
cles of mineral or metallic substances, occurs in persons employed 
in such occupations as coal-mining, the manufacture of pottery, steel- 
grinding, stone-cutting, tobacco-sorting, etc. Various names are thus 
applied to it, depending upon the nature of the inspired dust, — e.g., 
anthracosis, siderosis, calcicosis, lithosis, silicosis, etc. Unless, as is 
frequently the case, emphysema coexists, the affected lungs are harder, 
firmer, often smaller than normal, and usually of a blue-black, yellow- 
ish, or buff color, affording a striking contrast to the lung of a child. 
Even when the inspired dust is white, the lungs are apt to be of 
a dark color, due to the carbon and the altered blood pigment. In 
advanced stages of anthracosis an ink-like juice may exude from the 



DISEASES OF THE LUNGS 



169 



cut surface. In siderosis, caused by oxide of iron, the lung is of a 
reddish color. On section condensed portions of highly fibroid tissue 
are seen> with numerous raised points, which give it a coarse, granular 
appearance. These raised points are small, thickened, fibroid bronchial 
tubes protruding above the surface. The deposits are found micro- 
scopically everywhere along the course of the lymphatics. The pleura 
is usually adherent, thickened, and pigmented. The signs of chronic 
bronchitis are present, though the mucous membrane of the bronchi 
remains unpigmented. The bronchial and peribronchial glands as 
well as the peribronchial lymph-nodules are frequently intensely pig- 
mented, and may be either soft or indurated. The liver and spleen 
may also be pigmented. True osseous formations, coral-like in shape, 
may be found in the lungs. 

Traumatism. — In accidents foreign bodies may enter the lungs. 
In one case reported 1 a woman fell from a ladder and a broom-handle 
passed through her chest from one axilla to the other ; she recovered. 

Tuberculosis. — See p. 341. 

Tumors. — The benign tumors of the lungs are fibroma, adenoma, 
osteoma, and chondroma. Hydatids are common in countries in- 
fested by that disease, and may attain considerable size. Dermoid 
cysts are found, but very rarely. Primary malignant growths are 
rare, involving one lung only, while secondary tumors are compara- 
tively common, affecting both lungs. Carcinoma may originate in 
the epithelium of the alveoli, the bronchi, or the mucous glands. 
Secondary cancer is more frequent in women than in men and may 
be scirrhous, encephaloid, epitheliomatous, or colloid. Endothelioma 
starts from the lymphatic apparatus. Primary spindle-celled sarcoma 
and melanosarcoma are found, which often extend to the liver. The 
tracheal or bronchial glands are sometimes the seat of metastatic 
growths. In malignant diseases of the lungs, pleurisy, generally of 
a hemorrhagic type, is commonly present. 

Pleura. — Empyema (Pyothorax). — Suppuration in the pleural 
cavity is usually accompanied by the presence of air, and is due to 
pleurisy, extension of inflammation from neighboring organs, trauma, 
and micro-organisms, especially the tubercle bacillus, the Diplococcus 
of pneumonia, and the Streptococcus and Staphylococcus pyogenes. 
The pleurae are much thickened ; their surfaces are irregular and cov- 

1 Franke, Arch. f. klin. Chirurgie, 1903, vol. lxxi, no. 2, p. 543. 



I JO POST-MORTEM EXAMINATIONS 

ered with a yellowish-green exudate of varying thickness. There 
may be evidences of more or less extensive hemorrhage, also erosions, 
fistulse, or perforations. In severe cases there may even be gangrene. 
The pus separates into two layers, — a clear, greenish-yellow serum 
above ; a thick, cream-like pus below. It has a heavy, sweet odor, and 
is rarely fetid unless gangrene supervenes. A sterile culture on ordi- 
nary media suggests tuberculosis. 

New Growths. — The benign tumors of the pleura are fibroma, 
osteoma, chondroma, and lipoma. Endothelioma originating from the 
lymphatics may cause a diffuse thickening of the pleura. Teratoma 
has been reported, in one case attached to the tenth rib, aorta, and vena 
cava. Carcinoma and sarcoma occur, usually as secondary deposits. 
Hydatid cysts are very rare in this country. 

Pneumothorax. — This is the presence of air in the pleural cavity, 
and may be due to traumatism, tuberculosis of the lung rupturing into 
the pleura, other infectious granulomata, and malignant growths. 
The thorax is usually distended and the intercostal spaces may be 
obliterated. The introduction of a trocar allows the escape of the air. 
Unless pneumothorax kills suddenly, it is always accompanied by 
a pleurisy, generally of a purulent variety. The pericardium and 
heart are pushed or drawn to the opposite side. The lung is usually 
compressed and carnified and may be adherent to the chest wall at 
the apex, this site being frequently the seat of caseous nodules or 
cavities. Localized pneumothorax is probably often overlooked at 
the postmortem. 

Hydrothorax. — This is part of a general dropsy, and is usually 
due to chronic valvular disease, chronic Bright's disease, cirrhosis of 
the liver, cachexia, or pressure on the azygos veins. As a rule, it is 
bilateral, although not equal in extent in the two sides. The lungs 
are compressed and the pericardium and heart pushed upward. 

Hcemothorax. — This is generally due to trauma, sometimes to can- 
cer of the lung or pleura, also found with tuberculosis, purpura, scurvy, 
leukaemia, cirrhosis of the liver, and granular kidneys. 

Chylothorax. — An effusion of chylous fluid is rare, and is due 
to traumatic rupture or obstruction to the thoracic duct. 

Pleurisy. — Inflammation of the pleura may be acute or chronic. 
It is due to exposure to cold and wet, traumatism, extension of in- 
flammation from neighboring organs, pyogenic micro-organisms, 
many infectious fevers, infectious granulomata, or malignant tumors. 



DISEASES OF THE LUNGS 171 

Acute pleurisy is classified by the character of its exudate into serous, 
serofibrinous, fibrinous, purulent, and hemorrhagic. In all, the serous 
membrane is at first red, sticky, and lustreless, and the vessels are 
dilated; later it becomes pale, thick, and rough. The pleural cavity 
may contain an inflammatory exudate, varying in amount from a few 
cubic centimetres to one or more litres, resembling that seen in other 
serous cavities. The serofibrinous exudate contains more fibrin but 
less fluid. Coagula may be found in situ. The characteristic of the 
fibrinous exudate is the so-called " bread-and-butter" appearance of 
the pleura. The deposit varies in thickness from a millimetre to a 
centimetre or more. Purulent pleurisy may follow the acute form or 
may be primary. It is frequently associated with tuberculosis. The 
serous membranes are covered with a creamy exudate and the cavity 
contains from a few cubic centimetres to a litre or more of greenish- 
yellow, offensive pus. In the tuberculous exudate Ravaut and Widal 
have found a predominance of lymphocytes, while other effusions com 
tain polymorphonuclear neutrophils. Hemorrhagic pleurisy may be 
due to asthenic conditions, as tuberculosis and cancer, or may occur 
in perfectly healthy individuals, from wounds to the lungs during 
aspiration by the mixing of any fluid present with blood. The pleural 
cavity contains blood, usually fluid and varying considerably in den- 
sity. The serous membranes are generally inflamed and stained with 
blood-coloring matter. Chronic pleurisy with effusion may persist 
for months without undergoing any alteration in its character. The 
post-mortem appearances are very similar to those of an acute pleu- 
risy. Chronic dry pleurisy, resulting from the partial absorption of 
a pleuritic exudate and the organization of the remainder, occurs 
usually at the base, causing marked flattening of the chest. Small 
pockets of fluid are often found and it is frequently impossible to 
separate the layers of pleura. The lung is compressed, airless, and 
fibroid. Primitive dry pleurisy may be limited or universal, unilateral 
or bilateral, and may be accompanied by a similar condition of the 
pericardium and peritoneum. The layers of the pleura are firmly 
adherent to one another and, especially about the lower lobe, are much 
thickened. In tuberculous cases reddish-gray fibroid masses and small 
tubercles are present between the layers, sometimes infiltrated with 
serum. The bronchi may present marked dilatations and the pul- 
monary tissue be more or less sclerosed. In diaphragmatic, encysted, 
and interlobar pleurisy the morbid anatomy is similar. 



CHAPTER X 

CRITICAL EXAMINATION OF THE ORGANS OF THE ABDOMINAL CAVITY 

The Omentum, Mesenteries, and Peritoneum. — The super- 
ficial examination of the peritoneum having been made during the 
general inspection of the abdominal cavity, any thickened regions or 
surface irregularities are now felt with the index-finger and thumb, 
and, should anything abnormal be found, such areas are at once incised 
and critically studied. A regular order should be observed in the 
study of the peritoneum, — say, from above downward, — so that noth- 
ing of importance shall escape the attention of the operator. 

The peritoneum covering the diaphragm may become inflamed 
as part of a general peritonitis, or show the presence of aberrant 
pulmonary tissue, cysts, filaria, actinomycosis, lipomata, fibromata, en- 
dotheliomata, secondary tumors, etc. The Distoma hepaticum has been 
found embedded in the peritoneum of this region. Subdiaphragmatic 
(subphrenic) abscesses are not uncommon, especially on the right side, 
and may rupture into the pleural cavity or remain localized. In 
Korte's 1 sixty cases, which were operated on by himself, infection 
was found to originate most frequently from the vermiform appendix. 
Among the other causes giving rise to this condition may be men- 
tioned : (a) Perforation of a gastric or duodenal ulcer (most common 
cause), typhoid ulcer; (&) Abscess of the liver and pancreas; Rupture 
of the gall-bladder or bile ducts; inflammations about the kidney, (c) 
Diseases of the lower ribs, pleura, and mediastinum. 

A volvulus or hernial opening in the omentum may require 
removal, although, as a rule, it is better to make examination of any 
abnormalities or pathologic lesions that appear and afterwards to 
remove the omentum along with the transverse colon. In thin sub- 
jects the separation of the omentum into its four layers, one anterior 
and three posterior, forms a striking picture, especially if studded with 
recent miliary tubercles or the wild strawberry-like nodules of a sar- 
coma. The hsemolymph-nodes in man and in animals have recently 
been studied with special care by Warthin. They are found in greatest 

1 Gruneisen, Arch. f. klin. Chir., 1903, vol. lxx, p. 1. 
172 



EXAMINATION OF THE ABDOMINAL ORGANS 



U3 



numbers in the cervical and prevertebral regions, in the neighborhood 
of the adrenal vessels, along the brim of the pelvis, and in the root of 
the mesentery. The haemolymph-nodes are thought to be concerned 
in the destruction of red blood-corpuscles, and present pathologic feat- 
ures, especially in the various anaemias and leukaemias. 

The mesentery may be shortened by contraction, as following gran- 
ulations ; or lengthened, as by traction upon the bowel in a strangulated 
hernia, diastasis of the recti following pregnancy, or in enteroptosis. 
Congenital redundancy of the sigmoid flexure may be the cause of 
chronic obstipation and hypertrophy of the colon. Hemorrhage may 
take place into the mesentery in phosphorus poisoning and acute 
yellow atrophy of the liver. The glands are red and swollen in ente- 
ritis, especially in typhoid fever, where they may be very numerous 
and break down. They afford a favorable spot from which to secure 
cultures for the different varieties of colon and typhoid bacilli. When 
the glands become tuberculous, they may become very large and often 
caseate. In children they are normally proportionately larger than in 
adults. All statistics bearing upon tuberculous infection of these 
glands are extremely useful at the present time, in order to assist in 
determining the primary routes of infection and to place upon a sound 
scientific basis the relation of tuberculous milk to infant mortality. 
One also finds here enlarged glands in the leukaemias, particularly lym- 
phatic leukaemia, and Hodgkin's disease. By occlusion of vessels in 
this region the mesentery may become dark in color and cause many 
feet of the small intestine to become gangrenous. It may be wholly 
converted into a mass of fat. Search should be made for calcified 
tubercles, tumors, parasites, chylocysts, etc. Hemorrhagic infarcts are 
sometimes seen. Ortner has recently called attention to arteriosclerosis 
of the mesenteric vessels producing conditions in the gastro-intestinal 
tract clinically analogous to angina pectoris. In one of my post- 
mortems the infiltrated blood into the mesentery from a ruptured 
aneurism of the superior mesenteric artery showed the distribution of 
the blood to the mesenteries of the jejunum, ileum, caecum, vermiform 
appendix, colons, and rectum. It is well to remember that the duo- 
denum is not supplied with a mesentery. 

Secondary cancer of the peritoneum is found especially in the 
female sex, more often after the menopause than before, and is most 
often the result of metastasis from cancer of the stomach or ovaries. It 
is spoken of as " miliary carcinosis" because the nodules are small, 



174 



POST-MORTEM EXAMINATIONS 



spherical, and diffuse. The peritoneum is pale, thickened, with marked 
fibrinous deposits, which form adhesions to neighboring viscera, pro- 
ducing the condition spoken of as carcinomatous peritonitis; the 
omentum is indurated, and forms a mass transversely across the 
abdomen; the bowels are often firmly matted together. Ascites is 
usually found; the amount of fluid present may vary from a few 
ounces to several pints. In some cases of colloid cancer the secondary 
growths are of considerable size. 

Among the micro-organisms which have been demonstrated in acute 
general peritonitis may be mentioned the Streptococcus pyogenes, Ba- 
cillus coli communis, Staphylococcus aureus, Streptococcus lanceolatus, 
Bacillus proteus, Bacillus pyocyaneus, and, more rarely, the Gono- 
coccus (in the female) and anthrax and typhoid bacilli. The cause 
of the peritonitis is usually a perforation of the bowel, frequently 
the appendix. It may be: (a) Serous, (b) Serofibrinous, (c) Fibrin- 
ous, (d) Purulent, (e) Putrid. (/) Hemorrhagic, (g) Ulcerative. In 
acute general peritonitis the peritoneum has lost its lustre, is opaque, 
and is covered with an exudate varying with the type of the disease. 
The intestinal coils are, in places, distended, in other spots displaced 
and compressed, reddened, and glued together with lymph or 
fibrinous adhesions ; their walls are easily torn. The serous membrane 
may be easily separated from the muscular coat. In peritonitis 
due to perforation, the peritoneum and its contents are discolored by 
the faeces, while the peritoneal cavity contains gas, which escapes with 
a hissing noise when an opening is first made in the abdominal cavity. 

Causes of chronic peritonitis: (a) Follows the acute form, (b) 
Tuberculosis, (c) Extension of inflammation from the abdominal or 
pelvic organs, (d) Cancer. Classification. — (a) Local adhesive, (b) 
Diffuse adhesive, (c) Proliferative, (d) Hemorrhagic, (i) Local- 
ized peritonitis occurs about the spleen, diaphragm, liver, gall-bladder, 
intestines, mesentery, and pelvic organs. Bands of connective tissue 
more or less firmly organized bind the various organs together, produc- 
ing marked alterations in the appearance and position of the parts. The 
peritoneum is thickened and puckered. (2) Diffuse adhesive perito- 
nitis follows acute inflammation, of either a simple or a tuberculous 
nature. The abdominal cavity is often obliterated; the intestinal 
coils are firmly matted together by the plastic exudate, which eventu- 
ally becomes converted into bands of fibrous tissue. In this variety I 
have seen a central cavity produced which contained the entrance and 



EXAMINATION OF THE ABDOMINAL ORGANS ^5 

exit of several coils of the small intestines, the functions of life having 
apparently been carried on for a considerable time. (3) In the prolif- 
erative form there is great thickening of the peritoneum, which is 
opaque and white in color. The omentum is usually rolled into a thick 
mass between the stomach and the colon. The liver and spleen are the 
subjects of a chronic capsular inflammation; both are usually smaller 
than normal, with thickened, wrinkled capsules. There are seldom many 
adhesions, and serous effusion may be present in the abdominal cavity. 
The intestinal wall is greatly thickened and the mucous membrane of 
the ileum is thrown into folds. Nodular thickenings may be present 
and be mistaken for tubercles. (4) The hemorrhagic form occurs 
particularly in cancerous and tuberculous conditions. Layers of new 
connective tissue form on the surface of the peritoneum; they con- 
tain new blood-vessels, from which the bleeding occurs. It is com- 
monly a circumscribed process. Orth compares it to chronic internal 
hemorrhagic pachymeningitis. 

In order to obtain more room for the examination of the abdomi- 
nal cavity and a more favorable opportunity for the subsequent in- 
spection of the gall-bladder, biliary ducts, and portal vessels, the 
attachments of the diaphragm to the ribs on the right side may now 
be severed with the knife and the liver rolled over into the thoracic 
cavity of this side. (Fig. 121.) 

The Spleen. — The spleen varies greatly in size and weight, even 
during health and in the same individual at different times. Its nor- 
mal weight is about five ounces and the measurements are one and one- 
fourth by five inches. I have removed a spleen which weighed only 
one hundred and eighty-six and one-half grains (senile atrophy) and 
another weighing over seven pounds (malarial enlargement). En- 
largement of the spleen is seen in sepsis, typhus, typhoid, leukaemia, 
syphilis, etc. Remember that the spleen affords a favorable oppor- 
tunity for the study of micro-organisms, especially of the typhoid and 
colon groups. The spleen may now be removed from the abdominal 
cavity, although some pathologists recommend its excision later in con- 
nection with the pancreas. It is easily found by passing the hand along 
the left under surface of the diaphragm from the eighth to the eleventh 
rib, well towards the side and beneath the cardiac end of the stomach. 
Usually but little force is necessary to bring it into view, with the gas- 
trosplenic omentum and splenic artery and vein still intact. These 
parts are then cut or torn with a sort of twisting movement. In some 



Ij6 POST-MORTEM EXAMINATIONS 

cases the spleen is so soft that lacerations are very easily made in its 
substance by the fingers. These should not be mistaken for traumatic 
rupture of the organ, as from a kick, or for the rupture that sometimes, 
although rarely, results from disease. Occasionally the spleen is absent, 
its place being taken by a large number of supernumerary spleens or by 
an increase in the haemolymph-nodes of the abdomen. The spleen may 
be found attached to the surrounding parts, or a wandering spleen 
may be found displaced as far as the left inguinal region.. Before detach- 
ing the spleen, examine the course of the splenic artery for aneurisms, 
supernumerary spleens, enlarged glands, etc. When this has been done, 
the artery may be divided and the organ removed from the body. 
Notice whether or not the capsule is thickened, wrinkled, or opaque; 
it should be thin, smooth, and transparent. At times the capsule, from 
which trabecule extend into its pulp, appears as if melted tallow had 
been poured over the surface and allowed to harden. 

Now lay the spleen, resting upon the hilum (posterior surface), 
on the table, fix it with the left fingers, and with one stroke make a deep 
incision in its longest diameter. The spleen being turned, incisions 
transverse to those made upon the anterior surface may be made for 
further investigation. The color of the normal spleen is dark red but 
somewhat darker and of a bluish tinge in children ; it may be brownish 
from the presence of hemosiderin ; or yellow, as in jaundice or in the 
new-born, due to bilirubin crystals; or streaked with blue, owing to 
the presence of melanin. Coal-dust may be found in the spleen, 
having probably entered the circulation through the rupture of a peri- 
bronchial gland. Hyperplasia of the fibrous stroma in cases of chronic 
enlargement of the organ, as in malaria and leukaemia, may give the 
spleen a grayish tinge. 

The structure of the splenic tissue may then be examined, and 
the changes in the splenic pulp, the Malpighian bodies, and the 
connective-tissue trabecular noted. The elastic tissue of the spleen 
may be destroyed, as in tuberculosis, or hypertrophied around the 
capillaries, as in leukaemia. 1 A disturbance of the local circulation 
may lead to various changes. Oligemia is marked by the light-red 
or grayish-red color of the spleen, with wrinkling of the capsule and 
prominence of the trabeculae. Obstruction to the portal circulation 
causes congestion. Hyperaemia due to congestion in cardiac diseases is 

1 Fischer, Virchow's Archiv, 1904, vol. clxxv, no. 1, p. 69. 



EXAMINATION OF THE ABDOMINAL ORGANS 177 

characterized by an enlarged, hard, dark-red splenic pulp, with smooth 
surface on section and thickening- of the capsule, trabecular, and vessel- 
walls. In cirrhosis of the liver, particularly the hypertrophic form, the 
spleen is found to be usually enlarged, the capsule smooth and tense, 
and the splenic substance soft and friable. Infarcts of the spleen 
are common, and are usually wedge-shaped, with the apex towards 
the hilum. They vary in size from that of a pea to that of 
a cherry, and may at times include half of the spleen; they 
may become infected. Anaemic infarcts are of a cloudy-yellow color, 
while the less common hemorrhagic infarcts are very dark red, and 
later become yellowish red, and even whitish yellow as the coloring- 
matter of the blood disappears. Acute splenitis, resulting in the for- 
mation of pus, is not frequent. An acute proliferative splenitis, the 
cause of the so-called splenic tumor, is characterized by enlargement 
of the spleen, with the capsule markedly tense, and the pulp, 
on section, being of a vivid red, at first darkish and later somewhat 
lighter. The pulp is soft and exudes on section, thus concealing the 
Malpighian bodies. Fibrous, productive, or chronic inflammation of 
the spleen causes the chronic splenic tumor, recognized by the large 
size of the organ, which is hard, of a light or dark brownish hue, with 
thickened trabecular, that may appear as streaks through the splenic 
substance. The Bacillus aerogenes capsulatus was shown by Welch to 
be the probable cause of many cases previously reported as malignant 
cedema, emphysematous gangrene fondroyante, etc. Some of the deaths 
supposedly caused by the entrance of air into the veins may likewise 
have been due to this infection. At the postmortem, the muscles, the 
blood in the heart and great vessels, and the other internal organs may 
contain bubbles of gas. It has been known since 1857 tnat the Infuso- 
rium balantidhim coli, an oval-shaped ciliated organism, may cause 
intestinal infection in man and the orang-outan. A leukemic spleen with 
its umbilicated nodules is hard and of a reddish-gray color, sometimes 
weighing twenty pounds. Miliary tubercles, with caseation, and other 
tumors of the spleen occur. In the colored race miliary tubercles 
at times do not undergo caseation and may attain the largest 
size -of any developing in the body. I have not infrequently 
seen them as large as wild cherries. The arteries in the splenic 
pulp rarely show macroscopic atheroma, although the tissue of 
the spleen may be infiltrated with the salts of lime. The most 
important of all the forms of retrocedent disturbances of nutrition 



178 POST-MORTEM EXAMINATIONS 

of the spleen is amyloid degeneration. In this disease the spleen is 
firm and inelastic, so that the pressure of the finger leaves a decided 
mark. Amyloid degeneration of the pulp is characterized by the 
smooth, shining, almost transparent appearance of the cut surface, 
while the so-called sago spleen — the amyloid degeneration of the Mal- 
pighian bodies — is recognized by the enlargement of the lymph-nod- 
ules, which on section appear somewhat transparent and scattered over 
the cut surface. The amyloid reaction would be more frequently 
demonstrated if Lugol's solution were applied as a routine practice. 
A small piece of the spleen should also be tested for iron with ammo- 
nium sulphydrate. The Pentastomum denticulatum and echinococcus 
cysts of the spleen are sometimes found, as well as multiple 
angiomata, cancer, and sarcoma, the latter occurring, in rare instances, 
primarily in this organ. On healing, gummata leave behind stellate 
scars of varying size. 

The Intestines below the Duodenum. — When the exudation 
in the peritoneal cavity is fibrinopurulent and has a fetid odor, its 
source should be sought in a perforation of the intestine, although it 
may have originated elsewhere, as from the uterus or adnexa. If the 
peritoneal fluid suggest perforation, the gut may be examined under 
water, as pressure on the intestine will then cause bubbles of gas to 
appear. The site of perforation is usually marked by an area of 
fibrinous exudation, which may be so dense as to occlude the open- 
ing; or there may be several perforations, as in a case of typhoid 
fever. In duodenal ulcer the contents will be stained with bile. Ery- 
sipelas and poisoning by arsenic should be remembered as occasional, 
though rare, causes of intestinal ulcer. The exterior of the entire 
intestinal tract should be critically inspected, starting from below and 
going upward, and any adhesions should be very gently broken down, 
care being taken not to make an artificial opening in the bowel, — an 
accident quite apt to occur in certain diseased conditions. When, how- 
ever, the intestines are extensively agglutinated, as in appendicitis, 
tuberculous peritonitis, etc., the parts may often be better studied by 
first carefully noting their relations and then removing them en masse. 
Observe whether there be distention or contraction of the bowels. 
Distention is marked in cases of stenosis or strangulated hernia, and 
when a large amount of faeces is contained within the intestines. Con- 
traction is noted in enteritis and after starvation. Localized constric- 
tions may be due to bands of peritoneal adhesions. A Meckel diverticu- 



EXAMINATION OF THE ABDOMINAL ORGANS 



179 



lum : should not be overlooked, and its omphalomesenteric attachment 

going to the umbilicus should be searched for. It usually comes off 

at right angles from the ileum, about three feet from the ileocecal 

valve. Its proximal end may consist of several 

fingers or glove-shaped subdivisions. It is present 

in from one to two per cent, of the cases examined. 

The duct sometimes remains patulous until puberty, 

or may never close. The lymph-follicles may be 

injected, and are noticeable as irregular, whitish 

lines which, when pricked, exude a drop of milky 

fluid, — chyle. 

A proper examination of the intestines can be 
made only after they have been removed from the 
body. For this purpose the intestine is doubly 
ligated in three places, — viz., (1) at the end of 




the duodenum and the commencement of the jeju- FlG - 95— Method of 

passing the string through 
nUlTi; aS this portion Of the intestinal tract is an opening in the mesentery 

usually empty, this ligature is often omitted ; (2) in plevlous to ty,ng Jt - 
the ileum, several feet above the ileocecal valve ; and ( 3 ) at the end of the 
sigmoid flexure and the commencement of the rectum. The method of 
doing this is as follows : First, the contents of the intestine are milked 
backwards by catching the intestine between the thumb and forefinger, 
and a loop of string is then carried by the nail of the index-finger 
(Fig. 95) or a pair of forceps through an opening in the mesentery 
made with an instrument or the fingers and the intestine is ligated. A 
second ligature, far enough from the first to allow of the gut being 
divided between them later, is then to be securely applied (Fig. 96). 
Care should be taken that the ligatures hold tightly without slipping, 
so that no opportunity be afforded for the escape of fecal matter. 
The large intestine is then cut between the ligatures, and its proxi- 
mal extremity grasped and the mesentery severed by a sawing or 
fiddle-bow movement close to its intestinal attachment along the 
whole extent of the colon, until the ligatured spot in the ileum is 
reached, when the small intestine is incised between the ligatures. This 
portion is then removed to the sink or bucket preparatory to being 



1 See an interesting article by Zondek, Berliner klin. Wchnschr., August 
28, 1905, upon this subject. A case of congenital umbilical hernia containing 
Meckel's diverticulum is reported by Landman, Lancet, November 11, 1905. 



jgo POST-MORTEM EXAMINATIONS 

cleansed (Fig. 97), and the remainder of the ileum and the jejunum 
is removed, as seen in Fig. 98, and also placed in the sink or bucket. 
The intestines are opened either by pushing them into the open 
blades of the scissors or, better, by thrusting the enterotome or scis- 
sors through the bowels along the line of the mesenteric attachment 
(Fig. 99). Meckel's diverticula, like Peyer's patches, usually occur 
opposite the mesenteric attachment and, therefore, on the free anterior 
border of the ileum ; hence the reason for opening the bowel at its 
mesenteric attachment. The ileocecal opening is guarded by the two 
valves of Bauhin, the superior one normally overlapping the inferior. 
Each valve is to be examined on its ileac and csecal surface. The 
ileocecal cut is to be made between the two valves ; this is readily done 
by dissecting the ileum down to the valves, and then, as is usual, 
pushing the enterotome through the opening in the direction in which 
the intestinal contents pass, — i.e., towards the caecum and between the 
two valves. The appendix is better opened opposite its mesenteric 
attachment, contrary to the rule in the case of the intestines. The situa- 
tion of the valve of Gerlach is very variable. If a competent dead-house 
assistant is at hand, the opening of the bowel may be intrusted to him, 
as it saves the operator's time and prevents his hands from becoming 
impregnated with the disagreeable fetid odor of the gut. The assistant is 
instructed to save some of the contents for microscopic study and 
to call attention at once to any abnormalities observed. He opens 
all the intestinal tract except the ileocsecal valve and the vermi- 
form appendix, which are to be incised and examined by the patholo- 
gist himself. The small and large intestines, after being freed of their 
contents, should be measured and weighed apart, the ileocsecal valve 
counting with the large intestine. After washing, the entire bowel is 
arranged, mucous surface upward, upon the post-mortem table, so 
that the pathologist may at a glance examine the intestines throughout 
their entire extent. In cases in which haste is a matter of importance, 
the intestines need not be removed from the body, but at the end of 
the autopsy the region of the ileocsecal valve is opened as well as the 
sigmoid and rectum, and, if no lesions are discovered here, the remain- 
ing portion is left unopened, unless palpation or inspection in the 
preliminary examination of the abdominal cavity has led one to sus- 
pect a lesion in other situations. If a spigot is at hand, the open end 
of the intestine may be drawn over it, and the water allowed to run 
through until clean. Passage of water from a stopcock to cleanse 




Fig. 96.— Method of tying the intestines preparatory to their removal. They are tied in two places, 
a foot or so above the ileocaecal valve. 




Fig. 97.— Bucket method of opening and cleansing intestines, especially useful in private cases. 








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Fig. ioi. — Method of opening the kidney. The organ is held in the left hand with its hilum down- 
ward, and an incision is made with a brain-knife along its upper convex border and more than half 
through the renal substance. It is then reversed (Fig. 102) and the incision continued until the gland 
is nearly, but not quite, divided. In this manner there is no danger of cutting the hand. 




Fig. 102. — Method of opening the kidney in such a manner as not to injure the hands of the operator. 




Fig. 103.— Method of removing the capsule of the kidney with the bare hands. 




Fig. 104. — Method of removing the capsule of the kidney with the knife when gloves are employed. 



EXAMINATION OF THE ABDOMINAL ORGANS 181 

the intestines is not, however, always a proper procedure, as it may 
injure the mucous membrane, rupture a Peyer patch in a case of ty- 
phoid with ulceration, loosen some of the intestinal contents, change 
their consistence by admixture with water, etc. The bucket method 
of opening and cleansing the intestines — a very useful one in private 
cases — is illustrated in Fig. 97. In warm weather these viscera are 
particularly liable to undergo rapid decomposition after exposure for 
even a short time to the air. 

The color of the normal mucous membrane of the intestine is light 
gray, varying according to the contents of the bowel and the amount 
of blood present. Congestion of the small capillaries causes a general 
redness, while injection of the larger vessels produces red streaks; 
the two conditions may occur together. The greater the distention 
of the bowel, the paler is the grayish shade of the mucous sur- 
face, and if the contents of the gut are bloody the walls are dark red. 
This diffused color is to be distinguished from the redness due to 
hyperaemia, occurring in inflammations, congestions, etc., by the 
marked injection of the capillary blood-vessels which is seen in the 
latter case. Even the vessels of the submucosa are observed to be 
overfilled. Thickening of the walls as well as partial overgrowth of 
the mucous membrane, often in the form of small polyps, may be ob- 
served in many of the chronic inflammations of the intestines. En- 
larged villi, individually made out with the naked eye, may be noted 
in some cases of inflammation. (Orth.) In the leukaemias the lym- 
phatic nodules of the intestinal tract may be greatly hypertrophied and 
the intestinal wall may be the seat of amyloid degeneration when one 
of the usual causes of amyloidosis is present. 

The tabulation found on p. 354 will be found of use in distin- 
guishing typhoid and tuberculous ulcers. 

In cases resembling typhoid fever clinically the finding of paraty- 
phoid organisms may explain the occasional failure of the Widal test. 
A most careful study of all typhoid cases should, therefore, be made 
where the Widal reaction was not obtainable during life. The ana- 
tomic findings in the cases of paratyphoid fever 1 which have come 
to autopsy are those of septicaemia with splenic swelling and at 
times ulcers which resemble those of dysentery and do not seem to 
affect the Peyer's patches. 

1 Wells and Scott, Journal of Infectious Diseases, vol. i, January, 1904, p. 72. 



1 82 POST-MORTEM EXAMINATIONS 

Whether during life an enema may, by reversed peristalsis, 
be carried to the stomach and then vomited is an interesting but de- 
bated question which I believe should be answered in the affirmative. 
It is very difficult by pressure to force liquid past the ileocecal valve, 
but in relaxed conditions, as in cholera, this is perfectly possible. The 
problem is interesting as bearing on the possibility of a gastrocolic 
fistula and reversed agonal invaginations. 

Mayo Robson 1 has reported a case of peptic ulcer which devel- 
oped in the jejunum forty months after the performance of a gastro- 
enterostomy. A rare form of intestinal ulcer, not seen, however, in 
America, is that found in ergotism in Europe. 

An abundance of faeces in the large intestine indicates constipation, 
which occurs in an extreme form in partakers of opium, where one 
may find scybalous masses lying in pouches in the transverse colon as 
hard and dry as if they had been retained there for many weeks or 
even months. A similar condition is sometimes found in old persons 
subject to chronic constipation; the masses may even become encrusted 
with salts of lime. Distention of the small intestine shows that con- 
siderable food was recently taken. When the lacteals are well dilated, 
some three and a half hours have elapsed since the taking of the food 
which has reached this portion of the intestine. Pavlof finds that 
psychical secretion of the gastric juices varies markedly according 
to the character of the food ingested. When the faeces are light in 
color, an absence of bile is shown; when dark or light red, blood is 
probably present, although it must be remembered that medicines, such 
as haematoxylin, may give a similar appearance. When dark or black, 
the presence of iron or bismuth may be suspected; if yellow, the pos- 
sibility of rhubarb having been administered should be considered. 
Occult blood may be found. 

Gall-stones and worms may be found anywhere in the intestinal 
tract, but most frequently above the ileocaecal valve and in the lower 
rectum. In one of my cases I found, not far apart, two Tanice medio- 
canellatce, their heads being firmly attached to the mucous membrane 
beneath folds of the valvulae conniventes at the end of the duode- 
num. A specimen of ascarides in the Wistar and Horner Museum of 
the University of Pennsylvania shows where one of them had 
entered the bile ducts. As these worms try to escape from the 

1 Ann. Surg., August, 1904, p. 186. 



EXAMINATION OF THE ABDOMINAL ORGANS 183 

body after death, this may be an instance of post-mortem invasion. 
Seat-worms are found in the lower rectum. Packard removed post 
mortem, at the Pennsylvania Hospital, a specimen of Tcenia nana. The 
Anchylostoma americanum has been seen several times in Philadelphia. 
Loeb and Smith have recently pointed out the presence of a substance 
inhibiting the coagulation of the blood in the Anchylostoma caninum. 
Of course, any of the varieties of intestinal worms seen in man 
may be found at a postmortem, but it is surprising how few cases 
are described in the post-mortem notes of our hospitals. The foulest 
odors arise in icterus and dysentery, while in cholera the odor may 
be hardly perceptible. True intestinal sand may be found, and is 
largely composed of the phosphate and carbonate of calcium. It is 
most often caused by a purely milk diet or one of milk and lime-water. 
False sand, composed of biliary and fecal concretions, is more com- 
mon, being seen especially in the vermiform appendix. Salol, 
when taken medicinally, may cause the formation of crystalline 
enteroliths. In Brossard's 1 case, one of a number of calculi weighed 
two grammes. The tumors of the intestines are myomata, fibromata, 
polypi, lipomata, adenomata, carcinomata, and sarcomata, the latter 
variety being of rare occurrence. (Plate IV.) 

In hemorrhage of the bowel the bleeding may be localized or dif- 
fused. In the former variety petechial spots or ecchymoses are found 
on the mucous membrane. The mucous membrane surrounding the 
hemorrhages may be normal in appearance or show the results of active 
or passive congestion. In diffuse hemorrhages the blood is free in the 
bowel or may be extravasated into the mucous membrane. In the 
former case it is brownish black or black in color and usually semi- 
liquid or tarry. In the latter case the extravasated blood is in slate- 
colored or black patches. 

The Appendix. 2 — The average length of the appendix is about 
three inches, although it may measure as much as six. There is a 
mesentery often reaching to the tip and containing fatty deposits. The 
appendix is rarely absent and probably never double. Its usual direc- 
tion is towards the brim of the pelvis, but it may point in any direction. 
Appendicitis is most common in males and in early adult life, and 
is favored by fecal concretions, but rarely by foreign bodies. Among 

1 Bull. gen. de therap., 1897, vol. cxxvii, p. 363. 

1 The appendix has received special attention in the recent elaborate works 
of Deaver and Kelly. 



!84 POST-MORTEM EXAMINATIONS 

the articles found in appendices have been pins, fecal masses, calculi, 
worms, gall-stones, fish-bones, tip of a thermometer bulb, seeds and 
fruit-stones, as of grapes, cherries, prunes, etc. I have only found 
grape-seeds in the appendix three times, and then this organ was in 
no way diseased. In cases of ulcerative appendicitis with perforation 
at the head of the caecum, enteroliths have frequently been found. 
The theory has recently been advanced that influenza and syphilis 
are common causes of many cases of appendicitis. Metschnikoff thinks 
that the condition is often associated with worms of various sorts. 
Burfield * reports a case of Bilharzia infection of the appendix. 
The principal micro-organisms are the Bacillus coli (most common), 
Streptococcus pyogenes, Staphylococcus pyogenes, B. tuberculosis, B. 
typhosus, B. influenza, Proteus vulgaris, B. pyocyaneus, Actinomyces, 
B. pseudo tetanus, Micrococcus tetragenus, and B. ocdematis maligni. 
A mixed infection is usually present, upon an average three species 
being found in each case. The normal appendix is never sterile, while 
the diseased organ is sterile in ten per cent, of all cases. (Lanz and 
Tavel. ) Acute forms : catarrhal, follicular, ulcerative, suppurative, 
and gangrenous. Of the chronic : catarrhal, obliterative, and chronic 
infective. In acute forms the appendix is reddish brown, black, 
or greenish yellow in color. The mucous membrane is swollen, 
reddened, and presents hypertrophied follicles, ulcerations, or a false 
membrane. The whole appendix is thickened, the serous membrane 
red and lustreless. In the suppurative form the abscess may be 
small and limited to the appendix; when large the pus frequently in- 
vades the peritoneal cavity, the sac being formed by peritoneum, fibrin- 
ous exudate, and fibrous adhesions. It should be remembered that in 
cases of appendicitis abscess formation may start outside of the appen- 
dix and there be no perforation. In severe cases following ulcer- 
ative or obliterative conditions the abscess-cavity may contain the 
whole or a portion of the appendix which has been sloughed off. 
The abscess-cavity may become limited and remain so and be sub- 
sequently absorbed, or it may later open into the general peritoneal 
cavity. Rarely it breaks through the skin. It may, rupture into 
surrounding organs or structures, as the vagina, bladder, and rec- 
tum. The appendix may invaginate into the caecum and, by reason 

1 Lancet, February 10, 1906, p. 368. 



EXAMINATION OF THE ABDOMINAL ORGANS 



I8 5 



of its blood-supply being obstructed, become gangrenous, slough off, 
and be passed by the bowel. This, however, must be rare. 

Ulceration and perforation of the appendix following typhoid 
are found. In obliterative appendicitis the entire tube is thickened, firm, 
and stiff; the peritoneal surface is smooth or injected, and may be 
adherent or free. It may become cystic, the contents being clear fluid 
or pus. The situation of the appendix varies greatly ; rarely it may be 
found on the left side, as in transposition of the viscera, or it may be 
entirely absent. I have seen the tip of the appendix resting beneath 
a distended gall-bladder, entering into the formation of a left femoral 
hernia, or lying in the sigmoid flexure in a case of ileocsecal intussuscep- 
tion. On microscopic examination the lymph-follicles are numerous 
and close together, but as age advances they become separated and 
smaller. Late in life the appendix undergoes marked fibrous change, 
which must be distinguished from obliterative appendicitis. Primary 
cancer and sarcoma of the appendix have been found in a number of 
cases. Lafforgue 1 reports a double hydatid cyst of the appendix. 

More people die from dysentery than from plague, cholera, and 
yellow fever. The blood of patients affected with tropical dysentery 
has an agglutinative reaction with the bacillus of dysentery. For a 
description of the lesions found in this disease, see p. 315. 

In colitis, or inflammation of the large bowel, consider: (a) Early 
life, (b) Hot weather, (c) Errors of diet, (d) Certain micro-organ- 
isms of the colon group, (e) Poisons, (f) Some infectious diseases. 
Classification. — (a) Simple, (b) Membranous, (c) Ulcerative, (d) 
Chronic. ( 1 ) In simple colitis the mucous membrane is much thickened 
and reddened, the rugae are prominent, and petechial hemorrhages are 
common. In ordinary inflammation the follicles are swollen and 
cedematous and on section they appear like pearls. When there is a 
marked cellular increase, they are white or gray and more prominent. 
These follicles may become confluent. ( 2 ) Membranous colitis is char- 
acterized by the formation of a more or less complete cast of the intes- 
tine, usually from one to six inches in length, but it may extend a dis- 
tance of several feet. The membrane usually appears homogeneous, but 
may be distinctly laminated and show deposits of fecal matter between 
the layers. The end of the cast may be well defined, but often shades off 
into a transparent, gelatinous material. Associated with it are swelling 

1 Gas. des Hopit., January 12, 1904, p. 33. 



!g6 POST-MORTEM EXAMINATIONS 

and oedema of the submucosa. The mucous membrane not involved in 
the formation of the cast is very much inflamed and there may be hem- 
orrhagic infiltration. The intestine may show that perforation has 
occurred and gangrene may sometimes supervene. (3) In ulcerative 
colitis the appearances vary greatly : the ulcers may be small and numer- 
ous or they may be large in size and few in number. They may be per- 
fectly regular in outline, but are usually irregular, with slightly under- 
mined edges. The floor of the ulcer generally shows a somewhat 
sloughing bowel. The ulcers may have communications with one 
another between the layers of the intestines. In long-standing cases 
they are often intensely congested and tend to become transverse. 
Sometimes the floor of the ulcer becomes thin and is pushed out in 
the form of pouches. In very acute cases the mucous membrane is 
much reddened and highly vascular, and the surface is soft. The 
peritoneal coat of the bowel may be normal in appearance, but is usually 
red, somewhat sticky, and shows many dilated blood-vessels. Small 
hemorrhages are common. (4) In chronic colitis the bowel is often 
much thickened in all its coats. It may be larger in diameter. It is 
firm, even leathery, to the touch. The mucous membrane is hyper- 
trophied, often much pigmented, and shows many small hemorrhages. 
The follicles are swollen and have a slaty appearance. There may or 
may not be ulceration. 

There are four forms of dilatation of the colon: (a) Distention 
from gas. (b) Distention due to some solid substance within the 
bowel, (c) Distention caused by an organic obstruction in front of the 
dilated bowel, (d) The so-called idiopathic dilatation. 

Malignant disease of the colon is generally a cylindric-celled epi- 
thelioma, usually confined, in the earlier stages, to a small area, where 
its contraction sets up an annular stricture. 

The appendices epiploicse are a frequent cause of disease. I have 
often seen them strangulated by becoming twisted on their axis. They 
may even become calcified. 

The Kidneys and Adrenals. — The spleen and intestines having 
been removed and the liver turned over into the thorax,- the kidneys 
and adrenals yet remain behind the peritoneum, often deeply embedded 
in the perinephric fat. In anomalous cases, in certain diseases and 
deformities (notably Pott's disease), and in floating kidney they 
may be considerably displaced. In any event it is best and simplest 
first to find each ureter as it descends on the psoas muscle and enters 



EXAMINATION OF THE ABDOMINAL ORGANS 187 

the pelvis. The exact situation of the ureters is as follows : Each 
ureter at first passes obliquely downward and inward to enter the cavity 
of the true pelvis and then curves forward and inward to reach the 
base of the bladder. In its whole course it lies close behind the perito- 
neum and is connected to neighboring parts by loose areolar tissue. 
In its upper portion it rests upon the psoas muscle and is crossed very 
obliquely from within outward by the spermatic vessels, which descend 
in front of it. The right ureter is close to the inferior vena cava. Lower 
down the ureter passes either over the common or the external iliac ves- 
sels, behind the termination of the ileum on the right side and the sig- 
moid flexure of the colon on the left. Descending into the pelvis, it 
enters the fold of the peritoneum forming the corresponding posterior 
false ligament of the bladder, and, reaching the side of the bladder near 
its base, runs downward and forward in contact with it, below the ob- 
literated hypogastric artery, and in the male it is crossed from without 
inward by the vas deferens, which passes down between the ureter and 
the bladder. In the female the ureters run along the sides of the cervix 
uteri and the upper part of the vagina before reaching the bladder. 
(Quain.) 

Incise the peritoneum on the left side first, then on the right over 
and in the direction of the brim of the pelvis, and follow up each ureter, 
gently tearing away the loose connective tissue, but being careful not 
to disturb seriously the relationship of the kidney and adrenal and their 
vessels until they have been noted. If this method be adopted, there is 
no need of making an incision in the peritoneum directly over the 
kidney, as is recommended by most pathologists. A careful examina- 
tion of the vessels entering and leaving the kidney is next made, — 
vein, artery, ureter, etc., — all of them being subject to many anomalies. 
The left spermatic or utero-ovarian vein enters at right angles into the 
renal vein, which I have known to be followed out in mistake for the 
ureter. The organs may next be " shelled out" of their bed of cellular 
tissue and fat and the vessels severed, thus permitting their removal 
from the body. The adrenal 1 is then separated from the kidney, 
weighed, measured, and incised in its greatest plane. Should disease 
of the bladder or ureters be present, the kidneys may be removed from 

1 The right adrenal is more difficult to find than the left, and may be permitted 
to remain in the body until after the removal of the stomach, duodenum, and pan- 
creas, but should be sought for before the removal of the liver. Testut, quoted 
by Gerrish, gives admirable illustrations of the situation of the adrenals. 



iSS POST-MORTEM EXAMINATIONS 

the body with the ureters attached. This is always better in those very 
common cases in which double ureters are found. One nick is then put 
in the left kidney, so as to distinguish it from the right, at its upper 
or lower border, and the kidney and adrenal are removed, or the 
kidney may first be dissected. Another method of distinguishing 
the right kidney from its fellow is to make a uniform rule as 
to which ureter shall be left the longer, by several inches, on 
the separation of the kidneys from the body. The kidney is then 
cleaned and weighed, and any peculiarities are noted. 

To remove the kidney while the intestines are still in the body, 
first hold aside the left sigmoid flexure and pull away the fundus of 
the stomach and the tail of the pancreas. Then make an incision over 
the convex border of the kidney. Next separate it from the surround- 
ing tissue and cut the kidney out along with the adrenal. The right 
kidney lies under the liver, and in removing this adrenal be careful 
not to cut the inferior vena cava. If you remove the ureters with it 
(Fig. ioo), on the right side, a long incision must be made through the 
peritoneum that goes from the abdominal wall to the caecum and colon. 
( Orth. ) Nauwerck recommends a more complicated method. He cuts 
the descending colon from the mesocolon first. His primary incision 
is vertical and between the hilum and the spinal column, a second one 
being made in the convex border of the kidney. 

Holding the kidney longitudinally in the hand, the hilum towards 
the palm and the convexity upward, a clean brain-knife or large carti- 
lage-knife is used to divide it through its middle parallel to its greatest 
surface. The knife must be so sharp that it will cut without tearing, 
and care should be taken not to extend the incision through to the hand 
(Fig. ioi ) . The wisest precaution for this purpose is first to bisect the 
kidney only to its centre, then reverse the organ in the hand and com- 
plete the incision by cutting outward (Fig. 102). The pyramids and 
the calices with their papillae will now be completely exposed and the 
two halves held together by the tissues composing the pelvis. If it be 
desired to lay open the hilum or a hydronephrosis, scissors should be 
employed. Precipitates of urinary salts in the pelvis are often mis- 
taken for pus. A microscopic examination, especially if acetic acid 
be added, will at once reveal the true nature of the fluid. Now exam- 
ine the surface for cysts, stellate veins (veins of Verhagen), aberrant 
adrenals, miliary tubercles, tumors, etc. Large cysts can readily be 
seen. When incising a cystic kidney, it should be remembered that the 



EXAMINATION OF THE ABDOMINAL ORGANS ^9 

liquid therein is often under considerable pressure, and may squirt 
several feet when the cavity is opened, and thus injure the eyes or soil 
the clothing of the operator or of those present at the autopsy. 

The capsule, which when normal is transparent, is next stripped off 
from one side (Figs. 103 and 104), and its condition noted as to 
whether or not it is thickened, adherent, or non-adherent. If adherent, 
see if any of the cortical substance is removed with it, — i.e., whether the 
inner surface is smooth or rough. In those cases in which the capsule 
is adherent, this portion of the kidney should be saved for microscopic 
study along with the renal tissue lying directly beneath. The nor- 
mal color of the surface of the kidney after removal of the capsule 
is brownish red. 

The relation existing between the lighter cortex and the darker 
medulla is determined by drawing a straight line from the apex of one 
of the largest central cones of a pyramid to the surface of the kidney. 
Normally this relation is as one (cortex) to three (medulla) ; it is, 
however, frequently altered and should always be noted. The cortical 
substance is increased in parenchymatous nephritis and decreased in 
chronic interstitial nephritis. Also study the color of the external and 
cut surfaces, the quantity of blood or fluid exuding and its character, 
and the consistence of the organ. Thus, in parenchymatous nephritis 
the color of the cortex is a grayish white or light yellow. In poisoning 
by hydrocyanic acid much blood exudes, and in chronic interstitial 
nephritis the nephritic tissue is dense and hard. Both anaemic and 
hemorrhagic infarcts occur. The yellowish-white radiations found in 
the pyramids of infants' kidneys are composed of uric acid within the 
collecting tubules and are known as uric acid infarcts. Scars are often 
found, and may be due to many different causes, as gummata, thrombo- 
ses, infarcts, stones, former operations, etc. Tumors of the kidney, 
especially fibroids, are quite common. It is not rare to find numerous 
small fibroids just beneath the capsule which might be mistaken for 
tubercles. With arteriosclerosis and granular kidneys, never fail to ex- 
amine the brain, especially if there has been a clinical history that points 
to apoplexy. As a routine practice in the examination of the kidney the 
amyloid reaction should be tried. A thin slice about one inch square, 
including both cortex and medulla, is removed from the organ and 
placed in Lugol's solution (which is preferably diluted four or five 
times) for several minutes and then examined with a hand glass in a 
good light. In weighing the kidney the fat which is adherent — as 



190 



POST-MORTEM EXAMINATIONS 



found in old renal cases in the renal hilum — is weighed along with the 
organ, and unless its presence is mentioned may give a false idea as 
to the real weight. 

Where decapsulation as an operative therapeutic measure has been 
practised, also after the scraping of the hepatic peritoneum for ascites, 
the post-mortem examination should be very thorough, as any informa- 
tion concerning such cases is most important at the present time. 

The adrenals are covered by the under surface of the diaphragm, 
although not usually attached to it, and above and lateral to the tips 
of the kidneys. They are embedded in the same kind of tissue as sur- 
rounds the kidney, which is of a fatty, cellular nature, the difficulty of 
finding the glands being in proportion to the amount of this tissue 
present, which differs, however, in its color unless stained with bile. 
After the gland is found, its dissection is best accomplished by a 
pair of scissors. It is sometimes intimately connected with the 
kidney or even with the liver by bands of fibrous tissue. Acces- 
sory adrenals (generally discovered only by microscopic study of 
other parts) are found at times in the neighborhood of the main 
gland or even several inches away. Hydronephromata may be found 
in the kidney, liver, pancreas, broad ligament, spermatic cord, in the 
inguinal canal, or in the retroperitoneal tissue. They may assume a 
considerable size, and be either benign or malignant. The adrenal of 
one side may in rare cases be absent. Supernumerary adrenals are 
found rather frequently in the ox, being connected more or less inti- 
mately with the main gland. They must not be mistaken for the 
hsemolymph-nodes also found here. (Wynn.) 

The adrenals are best removed attached to the kidneys, though, as 
already stated, the ablation of the right adrenal with the kidney is more 
difficult than that of its fellow, and for this reason it is often left in the 
body and examined at the time of the removal of the pancreas. The 
adrenals are very delicate, and care must be exercised lest they be in- 
jured in their excision. Normally the adrenals consist of three layers, 
which differ more or less in the young and the old. The outer or cor- 
tical layer is light yellow in adults and grayish red in children. This 
tissue somewhat resembles that found in the thyroid gland. It is com- 
posed of radiating follicles whose cells are undergoing fatty degenera- 
tion. It will be seen in the new-born that the adrenals are relatively 
of large size in comparison with the kidneys and when examined 
microscopically no fatty metamorphosis is discovered. The inner or 



EXAMINATION OF THE ABDOMINAL ORGANS 



I 9 I 



medullary substance is composed of neuroglia and ganglionic cells 
connected with a rich vascular supply. The middle zone, or inter- 
mediary substance, is brown, owing to pigmentation of the follicles. 
The amount of intermediary substance is subject to considerable varia- 
tion. (Langerhans.) Later in life there is a tendency for the central 
part to become separated from the intermediary portion, 1 and in atro- 
phy of this organ, when it takes place unevenly (as it frequently does), 
nodes are left on the surface which are not infrequently mistaken for 
tubercles. These organs are subject to numerous pathologic changes 
and are hyperplastic in many varieties of congenital deformities in 
which other nerve-tissue is affected. There may be here haematomata, 
melanomata, cysts, gliomata, primary cancer, echinococcus cysts, hy- 
pertrophy, haematoid degeneration, tuberculosis, purulent infiltration, 
infarcts, and internal proliferations. The recent discovery of the 
marked action of adrenalin would seem to show the presence of an in- 
ternal secretion acting directly upon the vascular apparatus. Exquisite 
miliary tubercles are seen in the adrenals, and in advanced tuberculosis 
the caseating mass may reach the size of a walnut. 

Addison's disease is most frequently seen in laborers between the 
ages of twenty and forty years. It is by no means certain that the 
adrenals will be found affected, either macroscopically or microscopi- 
cally, in all cases of Addison's disease. It may be due to : (a) Tuber- 
culosis, simple atrophy, fibrosis, hemorrhage, or tumors of the adrenals. 

(b) Inflammation of and pressure by structures bordering the adrenals. 

(c) Changes in the semilunar ganglia and the sympathetic system. The 
adrenals are not infrequently tuberculous, and there is then a defi- 
ciency of the internal secretion of these organs. The brownish pig- 
mentation so characteristic of Addison's disease (bronze disease) 
is most marked on the chest. The spleen may be enlarged, as 
may also the thymus, if the latter gland be present. The stomach 
and intestines may show hypertrophied lymphoid follicles. No 
specific blood-changes have been observed. One of the most marked 
cases of pigmentation of the abdomen which I ever saw was that of a 
girl who had undergone an operation for the removal of a large der- 
moid cyst of the ovary. It is possible that in this case the semilunar 
ganglia or the adrenals were affected by pressure or otherwise. In two 



1 Letulle considers the formation of a central cavity as usually due to trauma- 
tism in its removal or to post-mortem changes. 



192 



POST-MORTEM EXAMINATIONS 



cases of primary sarcoma of the adrenal, and in one of general tuber- 
culosis with marked involvement by caseous tubercles of both adrenals, 
I observed no pigmentation of the skin at the time of the autopsy. 

The Semilunar Ganglia. — The semilunar ganglion or cceliac 
plexus, which receives the great splanchnic nerves and the pneumogas- 
trics, is situated behind the stomach and in front of the crura of the 
diaphragm, by the side of the cceliac axis and the root of the superior 



JZaik 




Fig. 105. — The relations of the pancreas, left kidney, ureter, adrenal, and solar plexus are shown, the 
liver having been turned upward and the intestines pulled over to the right. 



mesenteric artery, and close to the suprarenal body (Fig. 105). It may 
also be found by tracing the nerves from the adrenals to their entrance 
into the ganglion. The ganglia should be carefully studied micro- 
scopically in all cases in which lesions are suspected in the adrenals or 
in the sympathetic system. The color and vascularity as well as the 
condition of the surrounding connective tissue should be noted. In 
cholera and typhus fever the ganglia are hypersemic and may show 
evidence of the occurrence of hemorrhage (Rokitansky). 



EXAMINATION OF THE ABDOMINAL ORGANS 



193 



The Ureters and Bladder. — The ureters may be distended with 
urine, as from an impacted stone, stricture of ureter, twist of ureter 
(as in floating kidney), ligature, adhesions, or pressure from without, 
or from overfilling of the bladder. They are often double, most fre- 
quently uniting in their middle third, more rarely in the structure of the 
bladder, but may enter this viscus by separate papillae. The ureters 
being slit open throughout their entire extent, the appearance of the 
mucosa is described, taking into account the color and character of any 
catarrhal exudate, should it be present. Many microscopists teach 
methods of diagnosing the situation of a lesion in the urinary tract 
from the shape of the epithelial cells. A most interesting experiment 
is to take at a postmortem scrapings from the pelvis of the kidney, 
the ureter, bladder, and urethra, examine them under the microscope, 
and determine whether or not such a diagnosis is possible. Hemor- 
rhages, abscesses, papillary fibromata, the Distoma hcematobium, calci- 
fied bodies, etc., are found in the ureter. Miliary tubercles of the 
mucous membrane are seen, often of typic shape and large size. 

In some three hundred consecutive autopsies performed in one year, 
I met with three cases in which the ureter had been tied during abdom- 
inal operations on the uterus and its adnexa. The right ureter seems 
to be ligatured oftener than the left. In pregnancy there may be con- 
siderable pressure hydronephrosis. 

If it be desired to collect the urine for microscopic, chemic, or 
medicolegal examination, it should be drawn off into a sterilized vessel 
with a sterilized catheter. Should strychnine poisoning be suspected, 
place a live frog in the urine, and if strychnine is present in any amount 
the frog will show the typic strychnine convulsions. Unfortunately, 
however, in strychnine poisoning the quantity of urine secreted is 
often very small, and the alkaloid is not always present in the urine 
of those dying from its effects. 

Pelvic Organs. — Removal of the Female Genitalia. — The parietal 
peritoneum is freed around the entire brim of the true pelvis by a cir- 
cular incision, starting and ending at the symphysis pubis and including 
the anterior portion of the sacrum. Orth begins the incision between 
the rectum and the sacrum, while Schottelius recommends the ending 
of the incision at the posterior superior spine of the ilium. The body is 
then placed in the position seen in Fig. 106, and the thighs are sepa- 
rated. An oval incision is next made, starting above the external geni- 
talia, below the symphysis pubis, and ending behind the anus near the 

13 



194 



POST-MORTEM EXAMINATIONS 



coccyx (which may be examined at this time), passing to the outside of 
the labia on each side. Traction is then made upon the soft parts 
towards the median line and the incision deepened, keeping as close as 
possible to the pelvic bones and taking care that the knife or scissors, 
held so as to cut in the direction of the long axis of the body, does not 
injure the rectum, bladder, or external genitalia. It is now possible to 
remove the external genitals, bladder, and rectum through the abdom- 
inal cavity, or the internal parts through the oval incision exteriorly 




Fig. 115. — Method of opening the uterus ; the lines show the places for the incisions, one of which has 
already been started at the cervix. Letulle prefers to open the uterus posteriorly. 



(Figs. 107 to 114, inclusive). Whichever method is adopted, the mus- 
cles, fatty tissue, and fascia holding the parts in place are to be severed 
without injury to the tissues to be examined; or an internal or vaginal 
hysterectomy may be performed, if for any reason the external incisions 
should be avoided. If the ureters and kidneys have been left connected, 
they may be removed at the same time. The pelvic organs having been 
excised, they are placed on a board upon the table in the same relative 




Fig. 106. — Position in which the body is advantageously placed for examination of the rectovaginal region 
and for the performance of a postmortem per vagina?n or per rectum. The body is drawn down towards the 
end of the table and the hips are elevated with a block. The thighs are then strongly flexed and each one held 
securely in place by a separate bandage fastened beneath the table. 




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Fig. 117. — Author's method of examining testicles, epididymis, spermatic cord, etc., without 
disfigurement. The primary incision is made in the median raphe in such a manner as to be 
covered when the penis is returned to its normal situation. 




Fig. 118.— Testicles shelled out of the scrotum through the opening made in Fig. 117. 




Fig. 119. — Appearance .of the male external genitalia preparatory to min'ute examination in the 
author's method of exposing them without disfigurement. 



d c 




Fig. 120. — Method of examining the seminal vesicles, which are exposed by incisions at the places 
indicated by the lines above the seminal ducts, a, <z, edge of severed portion of peritoneum ; b, urinary 
bladder ; c, c, seminal vesicles ; d, d, spermatic ducts. (After Nauwerck.) 




Fig. i2i.— Relations of the ducts of the liver, gall-bladder, and pancreas to the duodenum. 
a, gall-bladder; b, liver; c, cystic duct, just above its junction with the hepatic duct; d, common 
bile duct ; <?, pancreatic duct;/", papilla in the duodenum, at which point the common bile duct 
and the pancreatic duct terminate. 



EXAMINATION OF THE ABDOMINAL ORGANS 



195 



position that they occupied while they were in the body. The bladder 
is then incised anteriorly with the scissors on the median line from the 
fundus to the urethra, which should be opened. In the male, the pros- 
tate should be carefully observed. 1 The rectum is slit up along its 
posterior wall, while an anterior incision is chosen through which to 
examine the uterus. When it is desirable to preserve the exterior of 
the bladder intact, the rectum may be dissected away and the womb 
incised posteriorly, or the bladder may be removed so as to permit of 
the uterus being opened up anteriorly. A transverse incision in the 




Fig. 116.— The uterus has been incised in the manner described in Fig. 115. The ovary and the tube 
are opened. The fimbriated extremity, the hydatid of Morgagni, and a corpus luteum are well shown in 
the illustration. 



uterus from the entrance of one oviduct to that of the other will give 
an opportunity for a study of their uterine termini, which are some- 
times rather difficult to find. Each ovary is completely bisected through 
its free surface, with the exception of enough tissue at the bottom to 
hold the two halves together (Figs. 115 and 116). The oviducts are 
now opened. Ch. Robin has pointed out that the normal mucous mem- 
brane of the oviducts secretes a creamy material which, without a 
microscopic examination, may be mistaken for pus. For the method 
of closing the external opening, see directions under Figs. 107 to 114, 



1 Many obducents partially open the bladder while it is still attached to the 
body; indeed, the entire examination of the pelvic organs can be made with the 
parts in situ. 



196 POST-MORTEM EXAMINATIONS 

inclusive. The older the ovary, the more is it distorted, irregular, 
and cicatrized. 

Removal of the Male Organs of Generation. — In the male the 
bladder is pressed downward well towards the rectum, and the tis- 
sues thus put on a stretch are incised close to the under portion of the 
symphysis pubis. A circular incision is then made anterior to the 
rectum and as close as possible to the parts to be removed (seminal 
vesicles, prostate, Cowper's gland, bulbus, etc.) without injuring them 
or buttonholing the skin. The soft tissues of the penis (cavernous and 
membranous portions of the urethra) are dissected away from the skin 
from within the pelvis, traction being made to bring these parts into 
the pelvic cavity as fast as those above are loosened. The corpora 
cavernosa and corpus spongiosum being now fully exposed, they are 
incised transversely near the attachment of the prepuce, just below the 
corona glandis and frsenum. By pulling on the spermatic cords from 
above and pushing up the testicles from below, these organs are then 
removed together. To facilitate removal, a few cuts may first be made 
into the internal inguinal ring. The skin of the penis and scrotum is well 
stuffed with cotton, so that they may conform as nearly as possible to 
their original shape. A preliminary symphysiotomy may even be per- 
formed, or a V-shaped portion of bone taken from the symphysis pubis, 
or, if desired, after dissection of the testes and their appendages, they 
may be returned to their normal situations. Unless by an accidental 
perforation of the skin, — as the knife is working in the dark, — there 
need be no visible deformity, if this method be properly carried out. 
The rectum and the bladder and its component parts may be left at- 
tached or they can be separated, as preferred. The testicles may also 
be removed and examined by dissecting beneath the skin in front of 
the symphysis pubis until their situation in the scrotum is reached. 
They are then pushed up with the hand from below. The tunica vagi- 
nalis and the spermatic duct and its vessels are then dissected out. 

The technic of my external method of examining the testicles, 
urethra, spermatic cord, etc., without mutilating or disfiguring the 
external genitals, is as follows : The penis is grasped with the left hand 
and drawn upward and backward over the symphysis pubis in such a 
manner as to expose its under surface and the scrotum. With the 
thumb and forefinger of the same hand a fold of skin is taken up at 
the point where the integument of the penis merges into that of the 
scrotum. This fold, which should be in the line of the long axis of 



EXAMINATION OF THE ABDOMINAL ORGANS 



197 



the penis, having been drawn taut, incision is made across it at right 
angles to the line of the penis. If this transverse incision be not 
carried too far, it will leave an oval gap about an inch and a half in 
diameter when the fold of skin is allowed to fall back. This will be 
quite large enough to permit the proper execution of the subsequent 
steps of the operation, and the wound, after being sewed up, is so 
small, that it is entirely concealed by the penis when replaced in its 
normal pendent position. The finger is next introduced into the 
scrotum and swept around so as to break up the delicate areolar con- 
nective tissue that forms the septum scroti and unites the dartos with 
the testes; then by slightly dilating the external wound the testicles 
can be removed from the scrotal sac. Next the root of the penis is 
grasped from within, and the extremely loose bands of connective 
tissue that unite the body of the organ to the integument are broken 
up, still using only the finger. These connections having been severed, 
the body of the penis can be drawn from its cutaneous sheath as far as 
the point of union of the prepuce with the tissues at the cervix, so 
that now the testes and the penis, as far as the glans, are exposed 
without their cutaneous investment. In severing the body of the 
penis from the glans and the tissue included in the inverted sheath of 
skin, great care must be exercised not to buttonhole the delicate 
structure of the prepuce. This accident can be avoided by amputating 
the glans at a point one-fourth of an inch from the corona (which 
can be plainly seen and felt through the delicate skin covering it) 
and carrying the incision parallel to its plane. The direction of the 
incision will be downward and forward, for in the position in which the 
integument attached to the cervix now holds the penis, the frssnum is 
below and in front. The amputation of the glans is most conven- 
iently performed with scissors, the body of the penis being supported 
by the thumb and first finger of the left hand (Figs. 117, 118, and 119). 
Nauwerck describes the following method of finding the seminal 
vesicles : They lie as long, flattened organs on the lateral side of the 
spermatic duct immediately above the prostate and the posterior wall 
of the bladder. The fundus of the rectovesical excavation is held up, 
and the index-finger is placed in the incision in the prostate, the middle 
finger in the posterior wall of the bladder, and' the thumb on the 
rectum, which on being pulled downward exposes the back part of the 
neck of the bladder, upon which rest the seminal vesicles. Or cut 
through the peritoneum in the depth of the excavatio rectovesicalis, 



198 POST-MORTEM EXAMINATIONS 

and dissect up the spermatic cord until the vesicles are reached. They 
are then to be incised and the duct opened up with a fine pair of 
scissors (Fig. 120). The mucous membrane of the seminal vesicles 
is of a brownish color, like that of the testicle. 

The Duodenum and its Ducts. — The duodenum may be slit 
while still in situ, or it can be excised together with the stomach, liver, 
and pancreas, and the whole dissected after removal from the body. 
If a careful dissection of the pancreas be desired, it is well to leave 
the duodenum attached to the stomach and not to dissect these parts 
away from the pancreas, which in the Russian language is so aptly 
called the " under-the-stomach gland." The length of the duodenum 
is determined by laying a string along the centre of its anterior sur- 
face and measuring the same. The gut is best opened with a knife, 
starting at the tied end about the centre of its anterior surface and 
with the enterotome cutting more and more to the right until at the 
pylorus the incision almost reaches the posterior surface' of the duode- 
num (Figs. 121 and 122). Notwithstanding the presence of the glands 
of Brunner in the lower third of the duodenum, the appearance of the 
mucous membrane closely resembles that of the jejunum. The papilla, 
the outlet of the ductus choledochus communis (common bile duct), 
can usually be discovered if it be remembered that it appears as an ele- 
vation of the mucosa near the junction of the second (descending) por- 
tion and the third (transverse or oblique) portion of the duodenum, 
about three and one-half inches from the pylorus, just below the head of 
the pancreas, and towards the inner and back part of the duodenum. 
The duct runs for three-quarters of an inch in the muscular coat of the 
bowel, where it is usually joined by the pancreatic duct. A small 
magnifying-glass will often enable one to distinguish the papilla from 
the valvulse conniventes. Pressure upon the gall-bladder, as sug- 
gested by Virchow, will cause bile to flow out (but care must be taken 
not to dislodge a gall-stone, either here or in the cystic duct) and thus 
reveal the opening of the duct. Another way is to follow down the 
cystic duct, make a transverse incision in it, introduce downward a 
small probe, a broom-straw, or a grooved director until this emerges 
through the opening in the papilla, and then slit it with a knife or scis- 
sors. Orth says that if, after finding the head of the pancreas, the intes- 
tines are stretched transversely, the outlet will readily be discovered a 
little below the middle of the head. Congenital diverticula of the duode- 
num are sometimes found, as well as those of the stomach and cesopha- 



Hepatic artery 



Liver 



Pylorus Stomach 



Portal vein 
Ductus chole- 
dochus 



Gall-bladder 



Duodenum 



Inferior vena 
cava 



Spermatic vein 




Portion of 
diaphragm 

/ 



Pancreas 



Ureter 



Spermatic vein 



Ureter 



Fig. 122.— Examining the bile ducts. The left index-finger is introduced into the foramen of Winslow 
and supports the hepatic artery, the portal vein, and the ductus choledochus, into the latter of which a 
sound has been introduced and is seen coming out of the opening in the duodenum. (After Nauwerck.) 




Fig 



123. — Method of examining the stomach, which in this case was markedly hypertrophied. 
gloves are very useful for this purpose. 



Rubber 




Fig. 124. — Removal of the liver from the body. It is held in the left hand and an incision is made 
towards the operator. This stretches the diaphragmatic attachments of the large blood-vessels, so that 
they may readily be incised. 



EXAMINATION OF THE ABDOMINAL ORGANS igg 

gus. Accessory pancreatic tissue may be found hid in the walls of the 
duodenum. The canal of Wirsung and its accessory canal should be 
opened. For this purpose the transverse incisions stop at the centre of 
the gland, and the canal is searched for. It is usually situated about the 
centre, is small in size, and is recognized by its pearl-like color. When 
found, it is dissected out until within about one and one-half centimetres 
of the ampulla, when a flexible probe or small grooved director is passed 
through the ampulla. The opening of the caruncula minor is often 
closed and the pancreatic fluid finds its way out from that portion of 
the pancreas drained by it by means of the ampulla of Vater, or the 
converse may be true. Branches from the canal of Wirsung, when 
dissected out, may lead to accessory pancreases. 

The Stomach and (Esophagus. — Unless poisoning be suspected 
(see pages 442 and 486), the stomach is incised along the greater cur- 
vature, a little below the cardiac orifice and a little above the pyloric, 
the contents are removed, and the openings examined, after which the 
incision is extended in both directions until the entire viscus is laid 
open. The mucous membrane may be washed by allowing a gentle 
stream of water, as from a sponge, to flow over it, but it should not 
be rubbed with the sponge. The organ may be opened and examined 
without removal from the body (Fig. 123). Should it be desired 
to find the artery from which a hemorrhage has occurred in a gastric 
ulcer, water is injected into the gastric artery supplying this area, and 
it will be seen to exude from the open part. The usual situation of a 
gastric ulcer is upon the posterior wall near the pylorus. Examples 
of a carcinoma developing from the edges of a gastric ulcer are some- 
times found. Guiteras has pointed out the frequency of small abra- 
sions of the mucous membrane near the pylorus and the collection of 
small round cells in this vicinity. These should not be confounded 
with post-mortem digestion of the mucous membrane. I know of no 
extended series of examinations of the gastric contents made after 
death. In nine cases of pernicious anaemia, Arneill x found free hydro- 
chloric acid in none, whereas it was present in some of the gastric car- 
cinomata examined. 

The contents of the stomach should be examined as to their quan- 
tity, consistency, reaction, odor, color, gas formation, and presence of 
foreign bodies. In one of my cases an aneurism of the thoracic aorta 

1 Amer. Med., January 16, 1904, p. 93. 



200 POST-MORTEM EXAMINATIONS 

had ruptured into the stomach. Blood coming from the lungs is 
apt to be mixed with air, frothy in character, and redder than blood 
issuing from the oesophagus or the stomach itself, where, if the 
vessel be of good size, large, compact, blackish- red lumps appear. The 
blood from cancer is blackish brown (the so-called coffee-grounds 
appearance) ; that from diapedesis, cirrhosis of the liver, and inflam- 
mations is a brownish, homogeneous mixture combined with mucus. 
The biliary pigments often impart to it a yellowish or greenish hue. 
Bile in the stomach and erosions point to vomiting during life. 
In peritonitis and in obstruction of the bowel the gastric contents may 
be fecal in character. 

The most unexpected articles may be found in the stomach, — gall- 
stones, hair-balls, scarf-pins, glass, rupees (in one case weighing 
seventeen and three- fourths ounces), hundreds of pins and needles, 
etc. Thus, eight teaspoons and seventeen other articles were removed 
by operation from a would-be suicide and thirty feet of wire from an 
insane patient. 1 Thieves often swallow articles stolen. The larvae 
of the Dipterce, maggots of cheese, earth-worms, ascarides, taeniae, and 
Oxyuris vermicularis and rhizopoda have been found. (Ewald.) 

The oesophagus is opened up along its anterior surface throughout 
its entire median extent, either while in situ, in case it has not been re- 
moved in the manner suggested on page 122 (Fig. 91), or after its 
removal from the body (Fig. 92). Its calibre may be directly deter- 
mined by graduated cones, or may be calculated by dividing its circum- 
ference by 3.14 (~). Its linear measurements can be made after it has 
been laid open. The longitudinal folds can plainly be seen, and may be 
discolored, due to post-mortem changes. Note carefully the change of 
color and elevation of the oesophageal epithelium as it passes into that 
of the stomach. Sometimes it is wise to differentiate by placing it in 
Miiller's fluid or in alcohol for several hours, thus coloring or bleach- 
ing the part. Traction diverticula are not uncommon, while pulsion 
diverticula are of rarer occurrence. An aneurism with a very small 
opening, usually slit-like, may rupture into the oesophagus. Collateral 
circulation is often established by means of the veins in the lower third 
of the oesophagus. Peptic, typhoid, syphilitic, and tuberculous ulcers 
occur here, as well as abscesses, congenital diverticula, and stricture 
due to a cicatrix, neoplasm, spastic contractures, etc. 

1 Monnier, Bull, de Vacad. de med., 1903, vol. lxvii, no. 34, p. 210. 



EXAMINATION OF THE ABDOMINAL ORGANS 2 OI 

In cancer of the stomach consider heredity, sex (more common in 
the male), age (average about fifty years), previous history of a gas- 
tric ulcer, and place of origin, inquiring particularly whether or not 
other cases have occurred in the same house. Cylindric-celled cancers 
are found especially at the pylorus, while squamous epitheliomata occur 
principally at the cardiac end of the stomach. The tumor may be hard 
(scirrhous) , soft (medullary) , or colloid, (a) Scirrhous. — The growth 
starts as a small nodule, usually at the pylorus, often sharply defined, 
and very hard. It is whitish on section and no cancer- juice exudes from 
the cut surface. Stricture of the pylorus with hypertrophy and dilata- 
tion of the stomach is common. Connective tissue is very abundant and 
cancer-cells are few. Ulceration occurs late in the disease, (b) Medul- 
lary. — This tumor tends to become larger than the scirrhous variety. It 
contains much less connective tissue and is therefore softer. It involves 
all the coats and is not circumscribed. It ulcerates very early and hem- 
orrhages are frequent. As in the previous instance, metastasis is very 
common, (c) Colloid. — This variety usually consists of gelatinous 
cancer-cells in a condition of colloid degeneration. It extends over the 
entire stomach and metastasis takes place very rapidly. Metastasis in 
all the forms affects the various tissues and organs in the following 
order: lymphatic glands, liver, peritoneum, omentum and intestine, 
pancreas, pleura, lung, and spleen. The squamous variety is a some- 
what flat, tubular swelling involving the superficial layers. It may 
constrict the oesophageal orifice and cause atrophy of the stomach. 
Cases in which a cancerous stomach has been removed entire during life 
demand special attention at the postmortem. 

Gastrectasis, or dilatation of the stomach, is due to: I. Pyloric 
Stenosis. — (a) Carcinoma, (b) Congenital conditions, (c) Hyper- 
trophy of the pyloric sphincter, (d) Cicatrix of an ulcer, (e) Peri- 
toneal adhesions. (/) Cancer of the head of the pancreas or other 
structure pressing on the duodenum, (g) Spasm of the sphincter. 
II. Atony of the Gastric Walls. — (a) From chronic gastritis, (b) 
Excessive ingestion of solids and liquids, (c) Traumatism, (d) Sur- 
gical intervention, (e) Serious infectious diseases. (/) Neurasthe- 
nia. (Hemmeter. ) At first there is hypertrophy of the muscular 
walls. Soon, however, interstitial sclerosis comes on, the stomach may 
become either pyriform or hour-glass in shape, and the mucous coat is 
thrown into exaggerated folds. As atrophy advances all the layers of 
the stomach become thinner; the bundles of muscles are separated by 



202 POST-MORTEM EXAMINATIONS 

connective tissue ; the surface may show evidences of pigmentation and 
petechial hemorrhage ; and while the serous surface sometimes remains 
unaltered, it is usually thick, pale, and opaque. 

Gastritis, or inflammation of the stomach: I. Acute. — (a) Errors 
in diet both as regards quantity and quality, (b) Irritant poisons. 
(c) Mechanical:' external (severe injury to the epigastrium) ; local 
(fish-bone, etc.). (d) Thermal (hot or cold ingesta). (e) Infectious 
diseases. (/) Psychic shock (grief, sorrow, etc.). (g) Extension 
of inflammation from other organs. II. Chronic. — (a) Follows re- 
peated acute attacks, (b) Slow poisons (alcohol, tobacco, gout, rheu- 
matism), (c) Errors of diet, (d) Anaemia and chlorosis. 

I. (a) In simple gastritis the mucous membrane is hyperaemic, 
swollen, and covered with much thick mucus. There are localized 
areas of ecchymosis and often small erosions. In severe cases there is 
considerable denudation of epithelium, with perhaps an exudate of 
grumous blood, (b) Phlegmonous or suppurative gastritis may exist 
in two forms: the abscesses may be small, multiple, and miliary, or 
they may be diffuse. The pyloric end is most commonly involved. The 
submucous and muscular layers are much altered, being swollen, 
(Edematous, purulent, and sometimes even bloody. The mucous 
membrane overlying the abscess may be normal in appearance, it may 
slough off, or, again, it may be swollen and hemorrhagic. Abscesses 
generally grow towards serous, and not mucous, surfaces. On the other 
hand, the surface is sometimes studded with numerous areas of focal 
necrosis of a yellowish appearance, and, on section, may discharge 
pus. (c) Diphtheritic gastritis sometimes follows laryngeal or pha- 
ryngeal diphtheria, and frequently accompanies pyaemia, scarlet fever, 
variola, and malignant endocarditis. In this form of gastritis we find 
a variable number of circumscribed areas of false membrane firmly 
adherent to the underlying structures and leaving a raw surface when 
removed. It is apt to attack particularly the crests of the rugae. The 
diphtheritic patches are usually surrounded by areas of more or less 
pronounced congestion, (d) In toxic gastritis the appearance of the 
viscus depends upon the amount of contained food at the time of 
ingestion and the concentration and kind of poison. If the latter is 
diluted, the mucous membrane alone suffers; if concentrated, all the 
coats may be involved. Alkalies appear to be more destructive than 
acids, the lesions produced resembling those of an intense congestion, 
more or less localized. Around an area of necrosis is a brown-black 



EXAMINATION OF THE ABDOMINAL ORGANS 203 

eschar. In very severe cases perforation may follow. Sloughs or 
ulcers are almost invariably found where the poison has been concen- 
trated. Mycotic gastritis may be due to : (a) Anthrax, (b) Favus. 
(c) Thrush. II. Chronic. — (a) Hypertrophic. — Virchow calls a 
condition of the mucosa when there are swelling, cloudiness, and a yel- 
low color, gastritis parenchymatosa or glandularis ; it is due to poisons, 
as arsenic and phosphorus, to acute infectious diseases, to acute atrophy 
of the liver, etc. This may be localized or diffuse. In the former case 
numerous mucous polyps can be seen over the affected area. This vari- 
ety occurs in drunkards. These warty elevations show considerable 
cystic degeneration. In the diffuse variety the stomach is almost invari- 
ably enlarged and the walls are thickened, particularly the mucous coat, 
which is decidedly velvety both to sight and touch, slate gray in color, 
with insular, deeply injected areas of scarlet and brown-red thickened 
patches. Besides being swollen, rugae are often present in exaggerated 
folds. Petechial hemorrhages and areas of pigmentation are common. 
There are often evidences of previous ulcerations (cicatrices). The 
stomach frequently contains a variable quantity of thick, tenacious, 
sour-smelling, greenish mucus, (b) Atrophic. — When this variety of 
the disease exists the walls of the stomach become thinner. There is 
connective-tissue overgrowth, which by its contraction causes the epi- 
thelial cells to undergo degeneration and disappear. The mucous 
membrane is thin, smooth, and pigmented. 

In hemorrhage from the stomach, if the blood come from without, 
as from a rupture of an aneurism, the stomach presents but few 
changes. The blood may be fluid or clotted ; it may be bright red or 
dark in color. When the hemorrhage is due to actual disease of the 
stomach, this blood is apt to be coffee-brown. Petechial hemorrhages 
in the mucous membranes are common. Extensive hemorrhage from 
the wall of the stomach is most usually associated with gastric ulcer. 
Behrend reports the autopsies of three cases in which death resulted 
from the diagnostic and therapeutic inflation of the stomach with car- 
bon dioxid gas. 1 

The Liver and Gall-Bl adder. — The clinician, having felt the 
lower border of the liver during life, often wants to know its exact 
situation at the postmortem, and is disappointed, on reading the report 
of the autopsy, if he does not there find what he desires. The attach- 

1 Med. News, December 19, 1903. 



204 



POST-MORTEM EXAMINATIONS 



ment and the presence of any lesions near the suspensory ligament are 
carefully noted. In the round ligament are sometimes found small 
collections of blood in places where this vessel has not become entirely 
obliterated. The bile may now be collected in a sterilized tube such 
as is described on page 383. The so-called " corset-line" produced 
by tight lacing may be due to other causes, as a pleuropneumonia or 
subphrenic abscess. The grooves at times running anteroposteriorly 
on the upper surface of the liver, known as Liebermeister grooves, are 
the result of pressure by hypertrophied portions of the diaphragm. 
Beaver-tailed livers of the left lobe are not infrequent. 

The liver is removed from the body by severing its attachments to 
the diaphragm, falciform ligament, blood-vessels, and ducts, and break- 
ing up existing adhesions. For this purpose traction is made by intro- 
ducing the left hand behind the right lobe and raising the liver so that 
it hangs over the ribs of the right side (Fig. 124). Nauwerck removes 
the organ by finding the hepatoduodenal ligament and then, intro- 
ducing the index-finger into the foramen of Winslow, pulling it some- 
what towards the duodenum and cutting, from right to left over the 
finger, the ductus choledochus to the right, the hepatic artery on the 
left, and, finally, the portal vein with its four main branches lying 
between the two posteriorly (Fig. 122) and quite constantly distended 
with blood. The liver is then weighed and measured, and the color, 
normally of a chestnut brown, and the condition of the surface are 
noted. The true color of the surface of the liver is best determined 
from an examination of its anterior aspect, as its lower part is apt to 
be bile-stained and, being in contact with the intestine, is more apt 
to show post-mortem changes. The right and left lobes may sometimes 
be measured separately with advantage. I have sometimes made a 
tracing of the outline of the liver by cleansing it from blood, placing 
it on paper, and then drawing with a pencil its outlines, indicating 
in their proper places any lesions which may be noted or the areas from 
which pieces are cut for microscopic study. As blood, when fresh, 
is quite adhesive, the paper must not be folded until any blood which 
may be on it has dried. After examination of the serous surface of 
the gall-bladder and duct, the sac should be laid open by a longitudinal 
incision carried through the duct. To find the ductus choledochus, 
first note the situation of the gall-bladder and then follow down the 
cystic duct either with the eye or by dissection to where the hepatic 
duct joins it. The bile duct running to the right of the portal vein 



EXAMINATION OF THE ABDOMINAL ORGANS 



205 



may then be dissected out to its outlet at the papilla in the duodenum. 
In case the liver is to be removed at once, the dissection should be 
continued beyond the place where it is to be cut. Should resistance 
be met in the passing of a probe during the process of dissection, 
such a part should be at once investigated. The hepatic duct may be 
opened with scissors until it has branched several times in the sub- 
stance of the liver. A bacteriologic examination of the bile ducts or 
gall-bladder may now be made. It will be recalled that the portal vein 




m^*T k n 








; -i!j*s«a&»^3 



Fig. 125. — Method of incising the liver. Long parallel incisions are made from the right lobe to the 
left, care being taken not to cut entirely through the organ, which would prevent reconstructing it to its 
normal state, nor to extend the incisions so deeply as to injure the gall-bladder. If desired, the liver may 
now be turned and a second set of incisions at a right angle to the first may be made upon its posterior 
aspect. The structures of the under surface of the liver have been previously dissected out in a manner 
similar to that described in the case of the lungs. The history of the case will usually give information 
as to which of the vessels may have to be sacrificed in the dissection. On p. 379 will be found methods 
for injecting the vessels with different colored materials. 

is formed by the union of the splenic and superior mesenteric veins 
and after running three or four inches divides in the liver substance 
into two main branches. The inferior mesenteric vein may empty 
into the splenic or superior mesenteric or take part in the formation 
of the portal vein. 

The liver is laid on its posterior surface and a series of parallel 
incisions about half an inch apart, which do not completely pass 
through the organ, are made, either longitudinally or, still better, 
transversely (Fig. 125). 



206 POST-MORTEM EXAMINATIONS 

In pernicious anaemia the presence of free iron may be shown by 
placing a thin strip of hepatic tissue in a ten per cent, solution of 
potassium ferrocyanid for several minutes and then washing it thor- 
oughly with a two per cent, solution of hydrochloric acid. The pro- 
duction of a blue color (Prussian blue) indicates the presence of iron. 
When Lugol's solution is applied to test the presence of the amyloid re- 
action, it is well to remember that the glycogenic reaction is also pro- 
duced by the iodin. A weak solution of the violet of Paris is recom- 
mended by Letulle for securing the amyloid reaction. Observe : Bile 
ducts : (a) calibre, — normally that of a thin goose-quill, may be closed 
or may be of the size of a finger; (b) gall-stones; (c) ulcers. Portal 
vein: (a) color of blood ; (b) thrombosis; (c) calibre, — may be thin, as 
result of old inflammation; (d) periphlebitis. I recall a case operated 
upon for cirrhosis of the liver where the postmortem showed an in- 
fected thrombus of the portal vein. Gall-bladder: (a) size; (b) 
adhesions; (c) tumors; (d) contents, — i, bile (note its color, — light 
or dark yellow, reddish yellow, greenish yellow, — quantity, quality, 
etc.); 2, foreign bodies, — gall-stones; 3, mucous membrane, — thick- 
ening, change in color, and inflammation. Liver: (a) position; (b) 
size, — increased in parenchymatous inflammation, decreased in atro- 
phy; (c) form, — fissures or granular distortion of surface; (d) 
color, — brown or brownish red normally, yellow in fatty infiltration, 
dark brown in atrophy, gray in amyloid and interstitial overgrowth, 
ochre-yellow in acute yellow atrophy, green in icterus, or dirty green 
when decomposition sets in; (e) consistence, — normally rather hard 
(pitting soon disappears), increased in amyloid disease, the pitting 
remaining for some time, softer in parenchymatous affections and 
early stages of acute yellow atrophy, fluctuates in echinococcus cysts 
and abscesses; (/) capsules, — normally transparent, but thickened in 
chronic inflammation, syphilis, etc. ; ( g) section, — smooth, uneven, 
rough, or granular; (h) lobules, — notice that they are separated by 
connective tissue, more distinct in cirrhosis, less so in acute yellow 
atrophy. It is well to remember that in man the separation of the 
lobules by the connective tissue of Glisson's capsule is not at all well 
marked. Observe whether the lobules are larger or smaller than nor- 
mal. Notice that the color is darker in the centre of the lobule than at 
its periphery (cyanotic induration). See if the periphery is yellow 
(fatty infiltration). On section note whether the tissues retract. Mil- 
iary tubercles are especially difficult of recognition in a hobnail liver. 



EXAMINATION OF THE ABDOMINAL ORGANS 2 OJ 

Pancreas. — The position of the pancreas having been determined 
in the preliminary examination of the abdominal cavity, its isolation 
and detachment are attended by no difficulty unless there* be disease 
of neighboring parts, in which case its removal may necessitate taking 
an additional viscus with it. Many students are singularly unfamiliar 
with the normal anatomy of the pancreas, the splenic artery often being 
mistaken for the pancreatic duct and the sensation of hardness which 
this gland normally imparts to the touch being regarded as an evidence 
of sclerosis ; the head and tail of the pancreas, too, are not infrequently 
left in the body and thus escape examination. In warm weather the 
pancreas is early affected with signs of decomposition, demonstrated by 
a brownish-red color, softening of its tissue, and the escape of a greasy 
brownish-red serum. Disease may extend from the pancreas to the 
portal vein, bile ducts, pylorus, or duodenum, or from these organs 
to the pancreas. Hemorrhages, tumors, degenerations, calculi (they 
may be found in the intestines), atrophic changes, cancer, cysts, etc., 
may be found in this organ. The possible presence of fat necrosis — 
a not infrequent cause of sudden death — should be borne in mind. 
The submucous, interstitial, or subperitoneal patches of pancreatic 
tissue in the wall of the intestine should not be forgotten. Accessory 
pancreases may be found in the stomach, intestines, and mesentery, 
the opening usually going to the intestinal tract. Langerhans's islands 
have been absent in nearly all the accessory pancreases examined. 

Examination of the Retroperitoneal Lymph-Glands, Dia- 
phragm, Vena Cava, Chyle-Duct, etc. — The retroperitoneal 
lymph-glands, best exposed by dividing the vertebral attachments of 
the mesentery at its roots, may be thickened from inflammation (as in 
syphilis) or be the seat of primary tumors (especially sarcoma and 
lipoma), secondary cancer, amyloid degeneration, and tuberculosis, 
or may have undergone changes due to various other inflammatory, 
cystic, and systemic affections. 

Examination of the diaphragm may reveal the existence of hernia, 
abscess on the under surface, perforation (as in echinococcus cysts or 
amoebic abscess of the liver), trichina spiralis, inflammation of its 
serous investment, fatty degeneration and brown atrophy, hypertrophy 
(as in obstruction to normal respiration), atrophy (as in pseudo- 
hypertrophic muscular atrophy and lesions of the phrenic nerve), etc. 
The muscular fibres of the diaphragm may undergo granular, cloudy, 



208 POST-MORTEM EXAMINATIONS 

or fatty degeneration. Traumatic rupture and congenital deficiency 
are occasionally met with. 

The vena cava and the aorta should be inspected for signs of in- 
flammation, thrombosis, etc. To remove the aorta it should be grasped 
as high up as possible, drawn forcibly forward, and cut obliquely from 
within and above outward and downward. In order to secure a firmer 
hold one finger may be inserted into its lumen. (Orth.) Its elasticity 
should always be tested by pulling both longitudinally and laterally. 
The color should also be noted and the presence of atheromatous 
patches and plates described, especially when found around or near the 
point of exit of its various branches. 

The receptaculum chyli rests behind the aorta, mainly on the body 
of the second lumbar vertebra, and between the pillars of the dia- 
phragm and the insertion of the psoas muscles. It arises from three 
roots which spread out over the third lumbar vertebra. As the tho- 
racic duct ascends, it crosses above the left azygos vein, and lies be- 
tween the aorta and the right azygos vein, and has a caliber of from 
three to eight millimetres. At the fourth dorsal vertebra it passes 
behind the oesophagus and opens into the left subclavian vein, at or 
near the entrance of the left common jugular vein. It is readily found 
by dissecting away, with an up-and-down movement of the tip of a 
grooved director, the cellular tissue situated at the top of the arch of 
the aorta and the oesophagus. This is near the left subclavian artery 
and before the duct which bends around this artery, like a shepherd's 
crook, to terminate in the vein. It has a rosy-white tint with longi- 
tudinal striae, and at this point gives off few collateral branches. The 
azygos vein is much larger and not nearly so elastic. It can be opened 
by splitting with a pair of fine scissors. The right thoracic duct emp- 
ties into the vena anonyma and collects the lymph from the upper part 
of the right thorax, neck, heart, and upper extremity. Failure to find 
the duct may be due to its previous removal while still attached to the 
descending thoracic aorta. Tuberculosis of the thoracic duct is quite 
common in abdominal tuberculosis. Leaf's translation of Cuneo and 
Delamere's The Lymphatics, contains much valuable information. 

Abscesses in the psoas muscles may be secondary to Pott's disease, 
coxitis, perforation of the intestine, tumors, etc. Examine the spinal 
column for kyphosis, lordosis, and scoliosis. In death after fright and 
from chloroform narcosis much blood is found in the abdominal veins, 
as the result of vasomotor paralysis. 



CHAPTER XI 

DISEASES OF THE GENITOURINARY TRACT 

Kidney. — No little confusion exists in the description of the patho- 
logic lesions of the kidney, owing to the multiplicity of terms employed. 
A classification of inflammatory renal diseases depending upon the 
structure affected is: (i) epithelial (parenchymatous or desquama- 
tive) nephritis; (2) fibrous (interstitial) nephritis; (3) vascular 
nephritis. Bright based his description clinically upon albumin in 
the urine and the presence of dropsy. The epithelial cells which elim- 
inate substances from the blood are granular, a non-granular variety 
lining the ducts. It should be borne in mind that there is no such 
thing as a perfectly pure form of nephritis and that the condition which 
predominates gives the name to the lesion. For example, when we 
speak of parenchymatous nephritis, we do not mean that the epithelial 
cells alone are affected without involvement of the connective tissue, 
for it is entirely proper to describe a case as chronic parenchymatous 
nephritis in which the interstitial changes are beginning to predominate. 
The character of the nephritis is frequently designated by the applica- 
tion of a term descriptive of some prominent features, as acute hemor- 
rhagic nephritis when petechial hemorrhages are prominent ; glomeru- 
lonephritis when the epithelium of the glomeruli is especially affected. 

Amyloid Changes. — These may be due to (a) prolonged suppu- 
ration (tuberculous or syphilitic), (b) chronic disease of the kidney, or 
(c) deficient cardiac compensation. The amyloid kidney is usually 
enlarged (the condition occasionally occurs in a contracted kidney), 
pale in color, and firm in consistency. The capsule is adherent in places 
and shows petechial hemorrhages beneath it. The cortex is increased 
in size. The glomeruli are first affected and usually prominent, 
although the cortex is pale in contrast to the somewhat reddish color of 
the pyramids. The organ has a bacony or waxy appearance. The 
urine contains albumin. The tube-casts are hyaline, waxy, or finely 
granular. (Edema of the extremities is common. The large white 
kidney may or may not show amyloid degeneration. 

Congenital Defects. — (1) Total absence. (2) Absence of one, 
with hypertrophy of the other. (3) Rudimentary, cystic. (4) Du- 

14 209 



2io POST-MORTEM EXAMINATIONS 

plication. (5) Partial coalition, usually lower end (horseshoe). (6) 
Remnants of fetal lobulation. 

Congestion. — (a) In traumatism the kidney is large; the capsule 
is tense; the color is dark red. On opening the capsule the contents 
are found to be soft and bulge out and blood drips freely from the sur- 
face of the section. The dependent portions are more congested than 
the cortex. In passive congestion the organ is enlarged and firm ; the 
capsule strips off readily ; the cortex is wider than normal ; the surface 
on section looks coarse and connective tissue is plainly visible; the 
cortex is of a deep-red color and the pyramids are of a purple-red. 
Congestion may be due to (b) drugs, as cantharides or turpentine, (c) 
infectious fevers, (d) alterations of the circulation in the kidney itself 
or in the vena cava (rare), (e) valvular lesions of the heart, (f) dis- 
eases of the liver, or (g) diseases of the lungs. Hematoma of the kid- 
ney occurs, sometimes reaching a large size and holding over a quart 
of blood and clots. 

Cystic Disease. — (a) Congenital cystic kidneys are greatly en- 
larged, so much so at times as to impede labor. There may be a con- 
glomeration of cysts varying in size from that of a pea to a small apple. 
In some cases no renal tissue can be seen without the aid of a micro- 
scope. The cysts are lined with flattened epithelium and contain a 
fluid in which are found albumin, blood-crystals, cholesterin, triple 
phosphates, and fat-drops, (b) Chronic nephritis (which see), (c) 
Adenocystomata, of similar origin as the corresponding cysts in the 
ovary, (d) Concretions block up the uriniferous tubules and press 
upon the still-intact epithelial cells, which later become flattened and 
disappear. The stroma and vascular supply are next affected and a 
cystic condition is produced, or the disease may progress to the forma- 
tion of large concretions. 

Hydronephrosis. — The outflow of liquid from the pelvis of a 
kidney may be obstructed by (a) congenital deformities, as when the 
pelvis comes off too high up on the kidney, (b) twists of the ureter, 
(c) calculi, (d) morbid growths, or (e) cicatricial bands. There is an 
accumulation of non-purulent fluid, which by steady pressure produces 
an atrophy of the organ and a gradual distention of its pelvis. The 
papillae become more flattened and disappear, and their place is taken 
by concave recesses in the medulla, which becomes narrower. In ex- 
treme cases the kidney may be converted into a large cyst with some 
imperfect septa. There may be an enormous quantity of the contained 



DISEASES OF THE GENITO-URINARY TRACT 2 II 

fluid or only a few ounces. It is yellowish in color and contains urea, 
uric acid, and sometimes albumin and sugar. There is usually com- 
pensatory hypertrophy of the opposite kidney. 

Infarcts. — (a) Calcareous infarcts extend through the tips of the 
papillae as stripes through one-half or more of the medulla, mainly 
along the canals, but also in interstitial tissue. There is effervescence 
on the application of hydrochloric acid, (b) Uric acid — found as acid 
ammonium urates in very young children and as acid sodium urates 
in mature years in cases of gout — may be deposited within the kidneys 
in the form of flakes (uric acid nephritis or gouty kidneys). In babes 
they appear as yellow radiations from papillae into medulla, and show 
that the child was born alive, as they occur only after breathing has, 
taken place. Sodium hydrate dissolves the acid ammonium urates. 
(c) Haemoglobin occurs in haemoglobinuria. It exists in the canals 
first as lumpy brown, later as granular, and seldom as crystalline 
masses. Haematoidin crystals are seen where old hemorrhages were 
(Virchow). (d) Bilirubin infarct gives the bile reactions. It occurs 
in the icteric new-born, in acute atrophy of the liver, and in pro- 
gressive pernicious anaemia, (e) Infarcts caused by salts of silver are 
very rare. (/) Hemorrhagic infarcts, (g) Anaemic infarcts. 

Interstitial Nephritis. — In acute interstitial nephritis the whole 
kidney is increased in size; the color is uniform, making it hard to 
distinguish the border line between the cortex (which is swollen) and 
the medulla. The process is essentially a productive one. There is a 
marked migration of the leucocytes and the connective tissue undergoes 
proliferation. The cells increase in number and the intercellular sub- 
stance disappears. Pus-cells lodge between the epithelial cells, and 
the lumina of the canals can no longer be followed. Such areas may 
be found anywhere in the kidney substance. The process is essentially 
due to pyogenic bacteria brought from the heart, as in malignant endo- 
carditis, or the uterus, as in puerperal sepsis. The process ends in 
abscess formation, often affecting the perinephric tissues. (Langer- 
hans.) A similar condition may start from without the kidney or 
extend up from the pelvis or farther down the urinary tract. 

Chronic interstitial nephritis may start as an acute form, but most 
frequently affects alone the connective tissue of its stroma, the blood- 
vessels not being involved. The process naturally ends in contraction. 
The canals are freed from their epithelial cells and the glomeruli may 
be brought so close together as to touch each other. The capsule is 



2I2 POST-MORTEM EXAMINATIONS 

adherent and the surface lumpy or granular and grayish red in color. 
The cortex is much smaller and may measure only a few millimetres 
in thickness, but its consistence is markedly increased. Compensatory 
hypertrophy may occur. If the canals are fatty they appear as yellow 
stripes or points. Cysts are common and are most marked at the junc- 
tion of the cortex and medulla. The vessel walls are thickened. Local- 
ized interstitial nephritis is usually syphilitic, while the diffuse form is 
due to gout, lithsemia, lead, over-indulgence, alcoholism, etc. In the 
latter form we have granular atrophy, the so-called red granular kid- 
ney, in which, as contraction takes place, cysts are found. 

Movable Kidney. — (a) Especially in females, (b) Due to absorp- 
tion of perinephric fat. (c) Repeated pregnancies, (d) Traumatism. 
(e) Displacement by tumors. As a rule, the displacement is not great. 
The kidney usually moves downward or upward and inward, generally 
rotating so that the outer border and upper end move forward and the 
hilum is directed inward and backward. Nearly all cases are associated 
with a medial displacement of the colon. The right kidney is the one 
most frequently affected. 

Parasites. — Of the parasites the following are found: (a) Dis- 
toma hcematobium (Bilharzia hcematobia). (b) Filaria sanguinis 
hominis. (c) Echinococci. (d) Cysticerci. (e) Pentastoma. (f) 
Strongylus gigas. All are rare in this country. 

Parenchymatous Nephritis. — Acute diffuse inflammation of the 
kidney is due to: (a) Acute infectious fevers, (b) Poisons, — e.g., 
turpentine, arsenic, etc. (c) Traumatism, (d) Exposure to cold and 
wet. Macroscopically the organ is swollen, tense to the touch as the 
capsule is stretched, but the substance of the kidney is softer than 
normal, the color is gray to yellowish, and the stellate veins on the 
surface are prominent. The capsule strips off easily and is somewhat 
thinner than when normal. On slitting the capsule the renal substance 
bulges out. The cortex, which is increased in amount, is somewhat 
pale, swollen, and soft ; the glomeruli appear as minute red dots. The 
pyramids are distinct and striated. The radiations in the medulla may 
be gray or transparent, gelatinous or watery. The larger blood-vessels 
are overfilled and prominent. 

Parenchymatous Nephritis, Subacute. — The large white kidney is 
more swollen than in the acute form and the tissue itself is of denser con- 
sistency. The width of the cortex may be increased, therefore, before 
contraction commences. Yellow spots where the degenerative changes 



DISEASES OF THE GENITO-URINARY TRACT 213 

are most marked are found in the gray glossy substance. Cysts are 
absent, unless interstitial changes are associated. The kidney is dry 
on section, and the pyramids of the medulla show reddened stripes 
pointing towards a papilla. This condition may be associated with 
amyloid degeneration, most marked in the glomeruli. The mucous 
membrane of the pelvis is frequently swollen and of a pinkish color. 
Microscopically the changes are those of an acute diffuse inflammation, 
including cloudy swelling, proliferation, desquamation, and a granular 
change in the cells lining the tubules. The straight collecting tubules 
may entirely escape, though there is a form of catarrhal nephritis, 
usually of an ascending variety, in which this part of the kidney is 
alone affected. In the surgical kidney there is an acute parenchymatous 
nephritis with abscess formations. Each individual cell is larger, the 
transverse diameter of the tubule increased, and the lumen diminished 
or even obliterated. Death most frequently takes place before the 
degenerative changes are complete; otherwise resorption and contrac- 
tion follow, and on the surface there are slight indentations, often asso- 
ciated with a hemorrhagic condition, hence bloody casts, as in poisoning 
by cantharides and potassium chlorate, where even pigmentary infarcts 
may be found. The urine is scanty, high colored, albuminous, and 
contains casts and free blood. There may be an extensive oedema,, 
with effusions into the serous cavities. 

Parenchymatous Nephritis, Chronic. — This process is latent and 
runs a slow course, often of years; not all of the kidney is affected 
at once, some portions showing normal parenchyma, while at other 
places degenerative changes are going on and at still others degenera- 
tion is complete and the parts are already in an atrophic condition. 
The cortex contracts irregularly, and has not the regular granular 
appearance seen in the kidney affected with interstitial nephritis 
(Langerhans), nor is there much increase in the stroma except at those 
places where contraction has taken place. 

Perinephric Abscess. — (a) Traumatism, (b) Extension of in- 
flammation from the kidney or from neighboring organs, (c) Per- 
foration of the bowel, (d) Infectious fevers, particularly in children. 
The kidney is surrounded by pus, a thick coating being found pos- 
teriorly. The abscess-cavity is usually extensive. The pus is often 
offensive and may have a distinctly fecal odor. It may burrow and 
discharge into the lung, bowel, peritoneum, or bladder, or it may follow 
the psoas muscle and appear in the groin. 



2i 4 POST-MORTEM EXAMINATIONS 

Pyelitis and Pyelonephritis. — Due to: (a) Tuberculosis, (b) Infec- 
tious fevers, (c) Calculi, (d) Cystitis, (e) Tumors. (/) Drugs, (g) 
Cold and wet. Classification. — (a) Simple catarrhal. (b) Puru- 
lent, (c) Hemorrhagic, (d) Calculous. In simple acute pyelitis the 
mucous membrane of the pelvis is swollen, hemorrhagic, and turbid. In 
the purulent form the mucous membrane is swollen and covered with 
a cream-like exudate of a yellowish or yellowish-green color. Ecchy- 
moses are common. The kidney itself is enlarged, softened, cedematous, 
grayish in color, and shows little distinction between cortex and 
medulla. Areas of necrosis or miliary abscesses are distributed through 
the kidney substance. The kidney may attain the size of a human head. 
It is usually firmly adherent to the adjacent organs, tissues, and vessels. 
A quart of pus may be contained in the cavity; in these extreme 
cases all traces of the gland substance may be lost. The hemor- 
rhagic variety occurs in anthrax, sepsis, and leukaemia. In calculous 
pyelitis the mucosa is roughened, grayish in color, and thickened. 
There are also more or less dilatation of the calyces and flattening of 
the papillae. These may be covered by a gray membrane. After the 
renal substance has been destroyed, if the pelvic orifice is still obstructed, 
the pus may become inspissated and ultimately impregnated with the 
salts of lime. 

Stones. — The following varieties of stone may be found in the 
kidney or its pelvis: (a) Oxalate. This is very hard, dark, brownish 
yellow or gray in color, with rough surface and of mulberry shape, (b) 
Uric acid. This is usually smooth or a little rough, light brownish 
yellow in color and often striped, and of medium consistence, (c) 
Phosphate stones are white, crumbling, and chalky, (d) Cystin and 
xanthin stones are rare. Shield 1 reports a case of gigantic renal cal- 
culus, removed during life, which when dry weighed over a pound. It 
measured 5^2 inches long. 

Tumors. — (a) Fibromata are the most common of benign tumors. 
(b) Lipomata. (c) Myxomata. (d) Myomata. (e) Angiomata. 
(f) Lymphadenomata (or lymphomata). (g) Rhabdomyomata. 
( h ) Carcinoma may be primary or secondary ; it is comparatively rare. 
The cancer may infiltrate the whole cortex or may be knotty and sepa- 
rated sharply from the surrounding tissue. (i) Sarcoma may be 
primary or secondary. It is more common than cancer, and may 

1 Lancet, October 15, 1904. 



DISEASES OF THE GENITOURINARY TRACT 2 I$ 

attain an enormous size. (/) A group of tumors usually occurring in 
children and containing various histologic elements, connective, mus- 
cular, and epithelial tissue, that Birch-Hirschfeld classes together as 
embryonal mixed tumors, (k) Patches of adrenal tissue may start 
growing and give rise to large tumors, the so-called hypernephroma 
heterotopes. Such growths are by no means rare. (/) Deposits of 
liver-tissue have been reported as occurring in the kidney, especially 
in the cortical layer. 

Ureters. — In some malformed foetuses both ureters are absent. 
In other cases double bilateral ureters are found. They may open 
into the vagina or the uterus. Stenosis often occurs as a congenital 
or acquired condition. Cysts and polyps are found not infrequently. 
Parasites, as the Distoma hccmatobhtm, round worms, and echino- 
coccus, are found. A calculus may fill the pelvis of the kidney and 
extend down in the ureter. 

Bladder. — The color of the vesical mucous membrane is normally 
a pale gray, but is red in recent inflammation and blackish red if the 
inflammation be very severe. The mucosa affords a favorite location 
for the multiplication of various organisms, which usually reach the 
bladder either from the kidney or from the urethra. Typhoid bacilli 
may frequently be detected in the urine of patients suffering from 
typhoid fever. Cystitis is due to irritants in the urine, extension of 
inflammation from adjacent parts, traumatism, septic infection through 
the blood of the urethra, infectious diseases, and most frequently occurs 
in stricture of the urethra, enlarged prostate, or diseases of the cord 
(myelitis). It may be ©edematous and especially hyperaemic after 
the ingestion of certain poisons, as phosphorus and cantharides. When 
cystitis is caused by the colon bacillus, the blood of the patient may 
give the agglutinative reaction in a dilution of one to fifty with this 
bacillus and thus show invasion during life. In acute cases the mucous 
membrane is swollen, reddened, and covered with a thin film of mucus 
or pus. The veins may be distended, especially when hemorrhoids 
exist and venous thrombosis occurs. When hemorrhage has occurred, 
the surface of the membrane is of a universal gray tint or mottled with 
gray, black, or reddish-brown patches. In severe cases necrosis, ab- 
scess, or even perforation may occur. In the diphtheritic form of the 
disease necrotic patches are seen and also small hemorrhages in the 
region of the trigone and the surrounding fundus. These tend to 
increase in size. There is submucous swelling, which subsequently 



2i6 POST-MORTEM EXAMINATIONS 

becomes infiltrated with pus. The whole mucous membrane over it 
degenerates and can easily be removed from the muscular coat. In 
chronic cystitis the bladder may be enlarged, but it is often smaller 
than when normal. The various coats are much thickened and there 
may be true hypertrophy of the muscular coat. This condition is best 
seen in cases of long-standing chronic cystitis, where the inner surface 
may even be thrown into folds and roughened so that the picture 
resembles that of the interior of a heart, and shows how difficult it is 
for injections into the bladder to cleanse thoroughly the walls when 
there is inflammation. In severe cases the inner coats often feel 
rough and sandy to the touch, on account of encrusted salts. Gangrene 
and tuberculosis may occur. There is a considerable variety of tumors 
to be found in the bladder : papilloma, adenoma, carcinoma, fibroma, 
myoma, sarcoma, cavernous angiomata, dermoids, and mixed tumors. 
Pockets (diverticula) may develop in the walls of the bladder, some- 
times being covered only by the peritoneum. Their openings may be 
very small, though the size of each diverticulum may reach that of a 
hen's egg. These pockets are at times produced by and may contain 
stones. In exstrophy the inner surface of the bladder is exposed 
externally above the pubes through a hiatus in the median abdominal 
wall. The intestines may protrude into or open through the bladder. 
Profe'ssor Guiteras once related to me an interesting case of primary 
diphtheria which developed upon this exposed mucous membrane. 
The organ may be completely or partially divided by an anteroposterior 
septum. The bladder may be entirely absent or may be double. Cases 
have been reported in which the two bladders were of the same size 
and located the one behind the other. The remnant of the urachus 
may undergo cystic change. In hypertrophy dilatation of the cavity 
exists along with increase in the thickness of the wall, which may 
exceed an inch. The female bladder may become inverted and appear 
through the urethra. It may also take part in hernise of various forms. 
The bladder may be ruptured by external violence, of which there 
may be no external visible sign. In overdistention the bladder may 
reach to the umbilicus. It may open into the rectum or vagina (vesi- 
corectal or vesicovaginal fistula). In the interesting condition called 
trichosis vesica? the hair is usually referable to the breaking of a 
dermoid cyst into the bladder or it may be a product of growth from 
the mucosa itself. In one case — an autopsy on a female — I could not 
see where the dermoid had arisen if not in the walls of the bladder itself. 



DISEASES OF THE GENITO-URINARY TRACT 2 IJ 

In a body examined at the Pennsylvania Hospital a bundle of hair 
was found which had become encrusted with salts, thus forming a 
calculus. 

Garrod 1 gives the following causes of black urine: (i) jaundice, 
especially when of long standing; (2) hematuria; (3) hemoglo- 
binuria; (4) hsematoporphyrinuria ; (5) melanotic sarcoma; (6) al- 
kaptonuria; (7) ochronosis; (8) abundance of indican; (9) long- 
standing pulmonary tuberculosis; (10) the taking of certain drugs 
and articles of diet ; (11) certain rare cases of undetermined nature. 

Vesical calculi, usually associated with some form of cystitis, may 
contain any of the normal or abnormal constituents of the urine. If 
this liquid be allowed to stand, precipitation occurs, the character of 
which depends upon the acidity or alkalinity of the urine. Bacteria 
in the body may cause an alkaline decomposition, with the formation 
from urea of carbon dioxid and ammonia, which uniting with the uric 
acid forms ammonium urates and triple phosphates. The most impor- 
tant sediments are uric acid, sodium urate, ammonium urate, — all of 
which give the murexid test, — calcium oxalate, calcium carbonate, 
calcium diphosphate, calcium triphosphate, and triple phosphate. Con- 
cretions may be found in the form of sand or as calculi. They are 
held together by an albuminous or cement-like substance, to which 
may be added cast-off epithelial cells, shreds of tissue, blood, mucus, 
etc. Primary stone formation may take place in urine which has not 
undergone decomposition; such calculi are usually composed of uric 
acid and urates. Secondary stone formation occurs in an alkaline 
urine, the starting-point being a foreign body introduced through the 
urethra from without or a small calculus which has found its way 
down from the kidney ; these stones are apt to be composed of ammo- 
nium urates and phosphates. They often consist of different substances 
concentrically arranged. Metamorphosed calculi are produced, for 
example, where a primary stone has been partially dissolved by the 
action of an alkaline menstruum and the remainder covered by sec- 
ondary deposits. ( Schmaus. ) Calculi assume a large number of shapes 
and differ much in size. In addition to those named above, cystin and 
xanthin stones exist. 

Parasites in the bladder are rare. The following have been found : 
(a) Distoma hcematobium (Bilharzia hcematobia) . (b) Filaria san- 

1 The Practitioner, March, 1904. 



2i8 POST-MORTEM EXAMINATIONS 

guinis hominis. (c) Echinococci. (d) Cysticerci. (e) Pentastoma. 
(/) Eustrongylus gigas. 

Female Genital Tract. — Fallopian Tubes. — One Fallopian tube 
may be absent or rudimentary, and, on the contrary, I have seen an 
oviduct lengthened to over ten inches by traction from a growing 
uterine fibroid, and have observed in a tube extra openings supplied 
with fimbriae, the presence of which might at times have an important 
bearing upon the question of ectopic pregnancy. This dangerous con- 
dition may occur anywhere within the tube, or the fecundated ovum 
may escape into the abdominal cavity or become caught in a corpus 
luteum of either ovary. It is doubtful whether ovarian extra-uterine 
pregnancy ever existed ; in two cases so diagnosed and brought to me 
for examination, careful study showed that fecundation occurred near 
the ostium, and the fimbriated extremities became attached to the ovary 
just as in a case of ovarian abscess, making it appear as if the preg- 
nancy had started in the ovary. Zinke tabulates a series of 88 cases 
of simultaneous intra- and extra-uterine pregnancies. An interesting 
abnormality is lithopedion, in which condition a fcetus may stay in the 
abdominal cavity for thirty or forty years with certain of its tissues 
remaining recognizable. The convoluted interior of the oviduct offers a 
favorable place for the growth of various organisms, especially the 
Gonococcus, the Streptococcus, the colon bacillus, and the organism of 
tuberculosis. The tube itself may be affected with cysts and with many 
kinds of benign and malignant tumors, the latter being primary or 
metastatic. It is subject to different forms of hemorrhage. 

In acute salpingitis the Fallopian tubes are swollen. The neigh- 
boring blood-vessels are dilated, tortuous, and overfilled with blood. 
There is often a considerable exudate on the serous surfaces, causing 
adhesions of the tubes to the surrounding structures. On section the 
lumen of the tubule is found to contain serum (hydrosalpinx), muco- 
purulent matter (pyosalpinx), or hemorrhagic fluid (hematosalpinx). 
The tube may rupture and give rise to a general peritonitis. The 
mucous membrane is thickened, swollen, and often intensely congested. 
To show the ciliated cells, though these may have been shed by the 
inflammatory process, care must be taken to harden the tissue at once 
after removal and according to the methods for showing karyokinesis. 
In chronic (proliferous) salpingitis the tubes may become enormously 
thickened, hard, and resistant to the touch. The adhesions to sur- 
rounding tissues are very marked and more or less completely organ- 



DISEASES OF THE GENITO-URINARY TRACT 2 ig 

ized. The new connective tissue may contract and so alter the appear- 
ance of the oviducts that they bear little resemblance to the normal. 

Ovaries. — These show perhaps a greater variety of pathologic 
changes than any other organ of the body. The ovary may be divided 
into lobes by bands of connective tissue, or actual duplications of the 
parts may occur. Supernumerary ovaries are found. An ovary may 
form part of a hernia; in a child, I found one in the canal of Nuck. 
The organ may be absent, hypoplastic, or prolapsed in an abnormal posi- 
tion. As the opportunity arises, study the differences between a true 
and a false corpus luteum and a corpus hsemorrhagicum. These glands 
are subject to various forms of inflammation, an entire ovary at times 
being converted into a pus-sac. They are often bound down by 
adhesions, and in later life undergo senile atrophy and may even 
become calcareous or calcareous concretions may be found in them. 
In certain conditions they may undergo hypertrophy. Among the 
tumors here found may be mentioned adenomata, dermoid cysts, which 
are of an almost endless variety, enchondromata, endotheliomata, fibro- 
mata, fibromyomata, myomata, cancers, cystomata, sarcomata, psam- 
mocarcinomata, angiomata, etc. Dropsy of follicles, fungous excres- 
cences, and tuberculosis occur. Dermoids of the ovary are closely 
related to malformations and pass without sharp division into true 
monstrosities. (Orth. ) Ovarian cysts may grow to an enormous size 
and weigh nearly 300 pounds. Wagner reports a case treated by 
puncture in which during eight years 9867 pounds of fluid were drawn 
off from the tumor. The ovaries may be enlarged in mumps. 

Uterus. — In examining the womb notice any abnormalities on the 
exterior and be sure to search every portion of the interior for any 
lesions which may exist. The situation of the organ may be markedly 
altered, and its individual parts may present abnormal relations to each 
other. Thus, we may discover anteflexion, anteversion, retroflexion, 
retroversion, prolapse, inversion, dilatations, elongations, bendings, or 
even find it forming part of an inguinal or a crural hernia. The chief 
congenital malformations are uterus bicornis, bicornis duplex, bilocu- 
laris, subseptus, and bipartitus, unicornis, didelphys, cordiformis, and 
septus duplex. The uterus is subject to atrophy, hypoplasia, rudimentary 
(infantile) atresia, stenosis, and hypertrophy. Uterine tumors are of 
great variety, — adenoma, adenocystoma, cancer, deciduoma malignum 
(syncytioma malignum), hsematoma polyposum, fibroma, myoma, 
myofibroma, myosarcoma, lipoma, leiomyoma, hydatiform moles, at 



220 POST-MORTEM EXAMINATIONS 

times to the number of several thousands, etc. There is considerable 
elastic tissue in a myoma; little or none in a fibroma. A placental 
polyp may assume destructive characteristics. Fleshy moles are 
the result of hemorrhage into the decidua. Dermoid cysts are found. 
Hemorrhages are common, and, besides those due to menstrual disturb- 
ances, are often associated with polyps, cancer, etc. After parturition 
and after the menopause marked changes take place in the blood-vessels, 
which may undergo hyaline or amyloid degeneration. Infarcts are 
seen. The ovarian veins should be especially studied in infections of the 
uterus, as by this channel arise infarcts and abscess in the kidney and 
lungs, and right-sided endocarditis. Many varieties of endometritis 
exist, such as gonorrhceal, tuberculous, diphtheritic, syphilitic, decidual, 
fibrous, gangrenous, glandular, interstitial, catarrhal, purulent, mycotic, 
villous, etc. Langerhans describes an interesting case of an old 
woman in whom the womb was so enlarged by a solid mass of thrush 
fungi and other bacteria that it measured some two inches in diameter. 
The uterus may rupture, as from childbirth, trauma, etc. A case is 
reported of a Csesarean-section scar rupturing at a following parturi- 
tion. Anspach considers that by an examination of the elastica it can be 
stated whether a woman has had children or not. 

In acute forms of endometritis the mucous membrane is red, 
swollen, and sodden ; the discharge is profuse, stringy, and often puru- 
lent; in severe cases blood is present. If infection follow contusion 
during labor, there may develop a suppurative process which, trans- 
forms the parts into a soft, stinking, grayish-green or brown mass 
that tends to become gangrenous. The cervix is the most often in- 
volved. In diphtheritic endometritis there is formed a thick, grayish- 
yellow or white membrane, the decidua lying loosely on the surface. 
The process may begin and remain at the placental attachment or may 
involve the cervical portion of the uterus. The infection may spread 
through the lymph stream or blood-vessels. Acute (ulcerative) endo- 
carditis is a frequent complication of puerperal infection. In hemor- 
rhagic endometritis the mucous membrane is red from engorgement 
of blood-vessels and numerous punctiform hemorrhages. < It is dis- 
tinguished by the condition of the ovaries from a similar appearance in 
menstruation. Tuberculous endometritis sometimes resembles carci- 
noma in gross appearance, but on microscopic and bacteriologic exami- 
nation shows the presence of tubercle bacilli. 



DISEASES OF THE GENITO-URINARY TRACT 2 2I 

In chronic hypertrophic endometritis there is a hyperplasia of the 
mucosa, with softening and congestion, forming polypoid excres- 
cences; the glandular structures also hypertrophy, become occluded, 
and form cysts of various sizes. In the cervix enlarged Nabothian 
cysts should be looked for. In atrophic endometritis the mucous mem- 
brane becomes thin and pigmented and the glandular structures dis- 
appear. Follicular erosion of the cervix occurs after lacerations. 

Foreign bodies may be found in the uterus. These are introduced 
to prevent conception or to produce abortion, or find place through sur- 
gical manipulation or expulsion from some adjacent organ. Twenty- 
four hours after the birth of a full-term child the uterus weighs from 
seven hundred to twelve hundred grammes. Friable, elevated, mush- 
room-like fibrous masses formed after the removal of the placenta are 
found in the area where the latter was attached. 

Vagina. — The vagina may be absent or appear as a mere connec- 
tive-tissue cord. It may be wholly or partially divided by a longitu- 
dinal or transverse septum. It may be entirety closed or so small that 
coitus, if attempted, takes place through the urethra, which thus be- 
comes markedly dilated. The normal flora is considerable, and of 
pathogenic organisms the Gonococcus, Bacillus diphtheria, and Oidium 
albicans (thrush) are of importance. It is well to remember that dip- 
lococci other than the Gonococci are frequently found in the vagina. 
After rape the condition of any secretion present should be noted, — 
whether dried, fluid, watery, or purulent; also its color and odor. 
Examine microscopically for spermatozoa and Gonococci. Observe 
all discharges in cases of abortion. Severe inflammation may follow, 
and even gangrene may supervene. Erosions, fissures, fistulse, and 
lacerations are seen after labor. Syphilitic ulcers are common; those 
of a tuberculous nature are rare. Tumors of the vagina include cysts, 
carcinomata, fibromata, fibromyomata, myxomata, rhabdomyomata, 
and sarcomata. Malignant neoplasms of the cervix uteri may by exten- 
sion of the growth involve the A^aginal walls, which should, therefore, 
always be examined in such cases. The epithelioma is almost always 
verrucose or nodose. Prolapse often accompanies tumors or is seen 
in multiparas accompanied by prolapse of uterus, rectocele, and cystocele. 
The exposed surface is eroded, and covered with ulcers and patches 
of necrosis. Vaginal hematocele, hernia, abscesses, and hypertrophic 
vegetations are not uncommon. Poisons, as mercury, phosphorus, and 
arsenic, may be found in the vagina ; at times used to produce abortions. 



222 POST-MORTEM EXAMINATIONS 

Male Genital Tract. — Testicles. — The testes are subject to 
many lesions, but the exposed situation and the extremely specialized 
character of these organs are sufficient to account therefor. The un- 
descended testicles are peculiarly liable to injury and favor the subse- 
quent development of tumors. Adenomata, sarcomata, enchondromata, 
fibromata, osteomata, myxomata, and rhabdomyomata occur. Dermoids 
and mixed neoplasms containing cartilage are not rare. Inflammation 
is common. In typhoid fever the condition of the testicles should 
always be noted, as they may become infected with the typhoid bacillus. 
They may be affected by syphilis, tuberculosis, leprosy, etc. In guinea- 
pigs infected with glanders the testes are especially apt to become dis- 
eased. Sarcoma and cancer of these organs are often indistinguishable. 
Cysts also occur, often combined with tumors. Hemorrhage may take 
place in the tunica vaginalis and the testicle may atrophy owing to 
pressure from the fluid in a hydrocele. True abscesses are found in 
them, and the testicles may show brown atrophy, glycogenic infiltra- 
tion, or pigmentary or amyloid changes. In elephantiasis they may 
show hypertrophy. The cords sometimes rupture and varix is common. 
Albers Schoenberg experimenting on guinea-pigs found that Rontgen 
rays caused necrospermia (in 197 minutes) and azoospermia (in 377 
minutes). Has radium a similar effect upon these organs? 

Spermatic Cord. — The cord may become twisted and thus cause 
testicular atrophy; this condition is, as a rule, associated with unde- 
scended testicle or swollen epididymis. The cord may be thickened 
or lobulated. Its arteries sometimes show marked atheroma and its 
veins, varices. I have also several times seen the duct itself converted 
into a rigid, thickened tube by salt-like deposits. 

Prostate. — The most common lesion of the prostate is enlargement 
due to interstitial hyperplasia. This is almost always accompanied 
by atrophy of the gland cells. Acute inflammation is very common. 
Abscesses occur; they are often not recognized until their sequelae 
are prominent, and are usually seen in the area around the posterior 
urethra. Cystic formation (cystic adenoma) is seen in many enlarged 
prostates, but true neoplasms are much less common. Carcinomata and 
fibromata are the most frequent. Moderate atheroma and endarteritis 
are seen almost always in the arteries of the part. In men over sixty 
years of age small prostatic calculi or sand, often dark in color, are 
quite commonly found on careful sectioning of the prostate. 



CHAPTER XII 

DISEASES OF THE LIVER AND PANCREAS AND THEIR DUCTS * 

Liver. — Abscess. — Hepatic abscesses may be multiple, often origi- 
nating from the appendix, or single, as in the amcebic abscess of the 
tropics. Perihepatitis is usually present, and rupture into the pleural 
cavity may occur. See Hepatitis, p. 229. 

Acute Yellow Atrophy. — This is an acute general disease described 
by Rokitansky in 1842, with special manifestations for the liver, 
presumably of infectious origin, characterized by a rapid fatty degen- 
eration of the organ, with invariably fatal termination. Due to: (a) 
A specific micro-organism ( ?). (b) The ordinary micro-organisms of 
suppuration and infectious diseases have been found in this condition. 

(c) Certain poisons give rise to a similar condition, — e.g., phosphorus. 

(d) Pregnancy or the puerperium. The liver is greatly reduced in size, 
— one-half to one-third ; in one of my cases, however, the condition had 
been preceded by hypertrophic cirrhosis and the organ weighed over five 
pounds. The liver is thin, flattened, and flabby, the capsule is wrinkled, 
and the gland is of a pale-yellow color. Both on the surface and on 
section may be seen a number of orange-yellow patches, in the centre 
of which are usually marked hemorrhagic areas in which the liver- 
cells have about entirely disappeared. The remainder of the liver is of 
a yellowish-brown or mottled color. The outlines of the lobules are 
very indistinct. The bile ducts and gall-bladder are empty. Bili- 
rubin crystals may be seen under the microscope. If a section of the 
liver be allowed to remain in the air for some time, a thin, white coating 
appears on its surface, which on examination is found to consist of 
crystals of leucin and tyrosin, which may also be found in the urine. 

1 Those wishing to go more deeply into this subject will find Waring's Diseases 
of the Liver, Gail-Bladder, and Biliary System (1897) and Opie's Disease of the 
Pancreas (1903) most instructive reading. Virchow's remark in his Post- 
Mortem Examinations (1876) of "the slight importance of the pancreas" is in- 
teresting as showing the small consequence attached even until a short time ago to 
the functional activities of this gland. An account of the " Zuckergussleber" and 
fibrous polyserositis will be found in Rose, Wurzburger Abhandlungen aus dem 
Gesamtgebiet der prakt. Medizin, 1904, vol. iv, no. 5, and Kelly, Trans. Coll. of 
Phys. of Phila., 1902, p. 62. Cam midge's article on the chemistry of the urine in 
diseases of the pancreas is contained in the Lancet of March 19, 1904, p. 782. 

223 



224 POST-MORTEM EXAMINATIONS 

The adjacent organs are usually stained with bile and present numer- 
ous hemorrhages, especially on the surface. The spleen is enlarged 
and the heart and kidney show marked fatty, hyaline, and granular 
changes. The color of the liver in acute yellow atrophy depends on the 
time at which death took place : in the earlier stages the organ is ochre- 
yellow, in the later stages it is mottled, and if much blood be present it 
is grayish red. The pathologic findings in the liver in eclampsia 
deserve especial mention. They are evident in every well-marked case 
of eclampsia and frequently present a striking picture. They consist 
of irregular areas of necrosis, grayish in color, intermingled with 
areas of diffuse hemorrhage. These changes are held by some to be 
the result of circulating toxins, by others to be caused by numerous 
minute emboli of liver-cells. 

Amyloid Degeneration. — Found in cases of: (a) Prolonged 
suppuration, tuberculous or syphilitic, (b) Infectious fevers, (c) 
Chronic visceral diseases with cachexia. The liver is large in size, 
smooth in outline, and pale in color. The edges are distinctly rounded ; 
small hemorrhages are common on the surface. On section the surface 
is anaemic, semitransparent, and infiltrated. It presents the character- 
istic lardaceous or waxy appearance. The process may be a localized 
or a generalized one; in either case staining by Lugol's solution is 
never uniform, as the diseased brown spots appear only in certain areas. 
The characteristic coloration may be seen upon the lining of both 
hepatic and portal vessels. Early in the disease this reaction is hard to 
detect, except by special stains under the microscope. Very thin pieces 
of the liver should be sectioned with a scalpel and put in a small glass 
dish. Add a solution of iodin and then wash out with water. Put 
something white under the dish and the characteristic coloration can 
be more readily seen. 

Bile. — T. Kimura 1 has investigated the bile taken from the human 
gall-bladder shortly after death. He finds its pigments to be variable 
in quantity, being low in tuberculosis and high in conditions of stag- 
nation, such as heart disease. The specific gravity varies from 1.012 
to 1.040, and the dry residuum from 2.68 per cent, to 20.63 P er cent. 
The relative viscosity varies widely, — from 1.46 to 58.24. These fac- 
tors are all greatly increased in cases of obstruction of the common 
bile duct. Urobilinogen is found regularly, urobilin very frequently; 

1 Deut. Arch. f. klin. Med., 1904, vol. lxxix, p. 274. 



DISEASES OF THE LIVER AND PANCREAS 225 

but both are wanting in cases of complete biliary obstruction, marked 
diarrhoea, and in the new-born. This fact supports the enterogenous 
theory as to the formation of urobilin. Normal faeces contain urobilin 
regularly, but it is wanting in cases of biliary obstruction. Meconium 
does not contain any. In a case of obstruction of the cystic duct, a 
hitherto undescribed brown pigment was found. 

Cancer. — I. Secondary Cancer. — Most common. Histologically 
shows same structure as primary growth, which is usually in the 
stomach, bowel, or pancreas. The liver is enormously enlarged, irregu- 
lar, and nodular. The nodules are usually symmetrical, often super- 
ficial, flattened, discrete, and umbilicated; they may be more or less 
evenly distributed throughout the liver. On section whitish masses of 
varying sizes are seen, contrasting with the red color of hepatic tissue, 
the yellow staining of bile, pigmentation due to blood, and the light- 
yellow areas of fatty degeneration. The cancerous masses may undergo 
fatty degeneration, suppuration, or fibroid change. II. Primary Can- 
cer. — Rare, (a) Massive. Causes great enlargement. On section the 
mass is uniform grayish white in color, somewhat firm, and distinctly 
outlined from the liver substance, (b) Nodular. Large and small 
nodules are scattered throughout the organ. These usually consist of 
a primary growth and numerous secondary nodules, (c) Cancer fol- 
lowing cirrhosis is rare. In such instances the liver is not much 
enlarged. Surface of section is grayish yellow, studded with nodular 
yellowish masses. In one of my cases of primary cancer of the gall- 
bladder the cancerous portions and the liver had become infected by the 
Bacillus pyocyaneus. 

Cholecystitis, Acute Infectious. — There exists an acute inflam- 
mation of the gall-bladder due to: (a) The introduction of pyo- 
genic micro-organisms, — for example, the Bacterium coli commune and 
the typhoid bacillus, Pneumococcus, Staphylococcus, and Streptococcus, 
(b) Gall-stones, (c) Extension of inflammation from the bile ducts. 
The gall-bladder is distended ; its walls are thickened and tense. The 
mucous membrane is swollen, hypersemic, and may be covered with a 
purulent exudate. The submucosa may also be involved. The contents 
of this sac are cloudy and dark in color, and may be mucopurulent or 
hemorrhagic. Orth states that the inflammation is usually of a necrotic 
character. The tissue is of a dirty yellow-brown color and sometimes 
is necrotic and easily torn. Gall-stones are frequently present. The 
cystic duct is often obliterated. There may be adhesions with the bile 

15 



22 5 POST-MORTEM EXAMINATIONS 

duct or omentum. The common bile duct may be congenitally absent 
and yet the child may live for some time, in one case five months. 1 The 
gall-bladder may be absent without serious impairment of the hepatic 
function. 

Cholelithiasis. — Gall-stones may be formed within the gall-blad- 
der or in the ducts leading to or from it. Consider: (a) Most fre- 
quent in females, (b) Age, fifty per cent, over forty years old. (c) 
Sedentary habits, (d) Overeating, (e) Carcinoma (?). (i) The 
calculi are usually multiple, rarely single. They vary in size as well as 
in number. When multiple they are faceted, sometimes mulberry- 
shaped. They are of a dark-bluish or greenish color. On section there 
is a nucleus consisting of epithelium, rarely a foreign body, then comes 
a layer of inspissated bile-salts, the outer covering being cholesterin. 
There may also be bile-acids, fatty acids, or salts of calcium and magne- 
sium, with a trace of iron and copper. When the stones consist of 
pigment exclusively, they are very easily broken and vary from yellow- 
ish-brown to black in color. When composed of cholesterin entirely, 
they are softer, easily indented with the finger-nail, but not brittle, and 
are crystalline, the crystals forming layers. They are colorless and 
more or less transparent, but turn blue when iodin and sulphuric acid 
are added. They generally consist of both pigment and cholesterin, 
which may be combined or may be separated in layers. These stones 
are usually firm in consistence, rarely friable. (2) The gall-stones 
may lead to impaction of the gall-bladder or to obstruction of the cystic 
and common ducts or even of the bile duct alone. There may be forma- 
tion of a fistula, external or internal, with escape of bile. The bladder 
itself is much thickened, sometimes dilated, sometimes smaller than 
normal through chronic inflammation. 

Cirrhosis. — Under this heading are classified various forms of 
disease of the liver characterized by a marked increase of its connective 
tissue, which may be capsular, interlobular, or intralobular, with or 
without increase or decrease in the size of the organ. Causes: (a) 
Alcohol, (b) Certain infectious diseases, — e.g., syphilis, tuberculosis, 
malaria, scarlet fever, (c) Micro-organismal infection. (d) Me- 
chanical obstruction to the onward flow of the blood, (e) Rickets. 
(/) Anthracosis. (g) Poisons, as phosphorus and cantharides. Clas- 
sification. — (a) Alcoholic, (b) Fatty, (c) Hypertrophic, (d) Cap- 

1 Menzies 3 Australasian M. Gaz., January 20, 1904, p. 20. 



DISEASES OF THE LIVER AND PANCREAS 227 

sular. (e) Syphilitic. (/) Cyanotic, (g) Malarial, (h) Scarla- 
tinal, (i) Tuberculous. (/) Rhachitic. (&) Anthracotic. (1) In 
the atrophic cirrhosis of Laennec (hob-nailed; whisky and brandy 
liver) the organ is greatly reduced in size, although in the beginning 
it may be slightly enlarged, and later is altered in shape. The surface is 
irregular and nodular and the capsule is thickened. The nodules are usu- 
ally small, but in some cases they may be greatly enlarged. The tissue 
is firm, hard, and resistant to the knife. The surface of section presents 
a mottled appearance, the lobules being divided by bands of connective 
tissue. The liver substance itself is of a yellowish or greenish-yellow 
color. The areas of connective tissue which are periportal are gray. 
(2) In fatty cirrhosis, found usually in drunkards, the organ is 
enlarged (even twofold or threefold), somewhat smooth, although 
often slightly granular. It is paler than normal and of a yellow- 
ish-white color. It is firm and resistant to the knife. The cap- 
sule is opaque and often much thickened. The peritoneal cavity 
usually contains ascitic fluid. The membrane is opaque and thickened. 
Chronic involvement of the stomach and small intestine is always pres- 
ent. The spleen is large and soft; the kidneys are often cirrhotic. 
Owing to interference with the portal circulation by the cirrhotic liver, 
extensive compensatory circulation is formed. The abdominal vessels 
above and below the umbilicus are markedly enlarged. Around the 
umbilicus is found the caput Medusa. Acute tuberculosis of the 
peritoneal cavity may be associated with it. (3) Hypertrophic 
(Hanot's) cirrhosis is most common in young men. Ackerman com- 
pares it to elephantiasis. The organ is enlarged, but the outline is nor- 
mal. The surface is usually smooth and its color an olive-green; the 
consistency of the organ is increased and the capsule is thickened. The 
surface of section is uniformly greenish yellow and the lobules may 
be separated by distinct bands of connective tissue. An intralobular 
growth of connective tissue occurs and also a considerable increase in 
the number of bile vessels. The spleen is greatly enlarged. Jaundice 
is a marked symptom of this disease. Ascites is usually absent. (4) 
In capsular cirrhosis there is enormous thickening of the capsule, which 
is irregular and somewhat wrinkled, producing great contraction of the 
liver. The organ itself is rarely markedly cirrhotic, its tissue being 
usually soft. Chronic capsulitis of the spleen, chronic perisplenitis, and 
ascites are often present. The kidneys usually show granular change. 
(5) In syphilitic cirrhosis the liver is markedly irregular in shape, 



228 POST-MORTEM EXAMINATIONS 

being divided into peculiarly shaped lobes by extensive bands of fibrous 
tissue traversing the organ in indefinite directions from healed gum- 
mata. In one of my cases over forty distinct lobulations were present. 
The cut surface is mottled, often fatty in appearance, and shows the 
presence of gummata or of syphilitic scars. The connective-tissue 
bands are of a gray or reddish-gray color. (6) For cyanotic cirrhosis 
see Passive Congestion of the Liver. (7) In malarial cirrhosis the 
liver is markedly enlarged, commonly extending to the level of the 
umbilicus. It is firm in consistence, of a dark-red color, smooth in out- 
line, and bleeds freely on section. (8) Klein has pointed out that 
chronic interstitial hepatitis may follow an attack of scarlet fever, 
which may account for some cases of cirrhosis of the liver in children. 

(9) Rhachitic cirrhosis is a form of the disease in which there is a 
marked increase of connective tissue around the individual lobules. 

(10) Anthracotic cirrhosis occurs in coal-miners, in whom the coal- 
dust may occasionally reach the liver in sufficient quantities to cause a 
marked connective-tissue formation about the portal canal. (Welch.) 
Sears and Lord, 1 from a study of seventy-eight autopsies of hepatic cir- 
rhosis, consider the condition to be part of a systemic disease. 

Congestion. — (a) Acute infectious diseases. (b) Traumatism. 
(c) Extension of inflammation, — e.g., from the intestines, (d) Val- 
vular heart-disease, (e) Pressure of tumors. (/) Other mechanical 
obstructions to the circulation. The condition is most marked when the 
veins of the liver are occluded, as in periphlebitis or Chiari's endophle- 
bitis. ( 1 ) The post-mortem appearances of active congestion are not 
characteristic. The liver is swollen, dark in color, and full of blood ; the 
hyperemia is not limited to any one portion of the liver substance. 
(2) In passive congestion the liver is large in size, smooth or slightly 
granular in outline, and of a distinctly mottled hue. The surface of 
section presents the characteristic nutmeg appearance (the centre of the 
lobule being darker, due to a marked congestion occurring in the 
central veins, the congested tissues being of a reddish-brown color. 
This is surrounded by a large area of a pale-yellowish color (fatty 
degeneration), with a third zone of cellular infiltration and new con- 
nective tissue. In rare cases this order is reversed, the congested area 
occurring at the periphery of the lobe and the lighter or fatty parts 
towards the centre. In chronic and well-marked cases there may be 

1 Bost. Med. and Surg. Jr., September 11, 1902, p. 285. 



DISEASES OF THE LIVER AND PANCREAS 229 

considerable induration and shrinkage of the liver substance, with 
irregular surface, so that the hypertrophy gives place to an atrophy, 
called cyanotic atrophy or Virchow's red atrophy. 

Emphysema. — Portions of the liver when squeezed under water 
show the escape of bubbles. This condition may be due to putrefaction 
or to the growth of gas-forming organisms during life, notably the 
Bacillus aero genes capsulatus. 

Fatty Changes. — (a) Middle life. (b) Alcohol. (c) Seden- 
tary habits, (d) Infectious fevers, (e) Certain poisons. (/) Ca- 
chexias, (g) Interference with local or general circulation. Classifi- 
cation. — (1) Fatty degeneration. The liver may be increased or 
diminished in size. The capsule may be smooth or wrinkled. The 
consistence is usually somewhat decreased; the organ is paler than 
normal and somewhat mottled in appearance. Periphery of lobule is 
first involved. The surface of section is smooth, usually bloodless, and 
imparts a greasy stain to the knife. The general color is a dull gray or 
grayish yellow. (2) In fatty infiltration the liver is often markedly 
enlarged, normal in outline, smooth to the touch, and of a somewhat 
pale, excessively fatty color. Globules of fat may be readily expressed 
with a knife. Hyperaemia may obscure the characteristic appearance. 
Recent investigations tend to show that fatty degeneration and fatty 
infiltration are not distinct pathologic processes, but rather that they 
are differences in degree of infiltration. 

Hepatitis, Suppurative. — Abscess of the liver may be due to: 
(a) Traumatism. (b) Extension from neighboring organs, — e.g., 
the bowel and the pleura, (c) Pyaemia, (d) Amoebic dysentery. 
(e) Malignant emboli. (/) Diseases of veins, as periphlebitis 
and thrombophlebitis. (g) Stoppage of bile, as from gall-stone 
or dead ascarides. (h) Idiopathic tropical disorders. Clas- 
sification. — (a) Pysemic hepatitis, (b) Portal pyaemia, (c) Pyo- 
septicsemia or multiple abscess, (d) Tropical or endemic hepatitis. 
(<?) Suppurative cholangeitis. (1) In multiple abscess the change in 
the liver depends upon the number of the abscesses. If these be few, 
the liver tissue may be comparatively little altered ; if they are very nu- 
merous, the liver is apt to be enlarged, softened, and friable. The ab- 
scesses themselves appear as minute foci which are non-capsulated, 
the centre containing a thick white, yellow, or greenish pus surrounded 
by a zone of congestion. The abscesses may vary in number from five 
or ten to many hundreds. These multiple abscesses frequently arise 






230 POST-MORTEM EXAMINATIONS 

from pygemic embolism of the portal vein or hepatic artery or vein, or 
they may result from a cholangeitis. They may be generally distributed 
or appear in clusters. If from a malignant endocarditis, they are 
usually situated under the capsule. (2) Large abscesses occur in two 
forms, — the large chronic encapsulated abscess surrounded by a pyo- 
genic membrane and the tropical or amoebic abscess. (See Dysentery.) 
The large abscess is usually single, but there may be two or more. The 
right lobe is usually affected. There is a distinct limiting membrane. 
The pus is usually of a greenish-yellow color and often of a disagree- 
able odor. The surrounding substances often show but few changes, 
except as the result of pressure. 

Sarcoma. — This may be primary (very rare) or secondary. The 
most frequent variety is the secondary melanosarcoma following sar- 
coma of the eye, of the skin, of the dura mater, or of the penis. In these 
cases the liver is greatly enlarged, weighing as much as fifteen pounds, 
and the secondary nodules, which are of a black or slate color, are 
usually uniformly distributed throughout the gland. In primary sar- 
coma of the liver there are but few nodules, and these reach a large 
size, measuring at times five or six inches in diameter. Metastases to 
other organs often occur, though other portions of the liver may escape. 

Other Tumors: — In addition to carcinomata and sarcomata, the 
liver is the seat of adenomata, adenocystomata, angiomata, fibromata, 
and aberrant adrenal tumors similar to those found in the kidney. The 
cavernous angiomata are usually small in size and, when found, are 
usually seen on the surface of the liver in elderly persons. They may 
be injected with colored material by means of any of the hepatic blood- 
vessels, and then form excellent microscopic specimens for future study. 
A cystic liver may be associated with a similar condition of the kidneys. 

Parasites and Infectious Diseases. — Psorospermice, Pentastomum 
denticulatum, Distomum haematobium, Distomum lanceolatum, Dis- 
tomum hepaticum, and Echinococcus. Cases of primary tuberculosis 
Df the liver have been reported, and syphilitic lesions are by no means 
rare. 

Pancreas. — Anomalies. — The tail of the pancreas is sometimes 
bifid, and peculiar divisions made by septa of connective tissue may 
occur in all parts of this organ. The pancreatic tissue by surrounding 
the duodenum may cause an intestinal stricture. Accessory pancreases 
have already been referred to in detailing the technic of removing 
the gland from the abdominal cavity. 



DISEASES OF THE LIVER AND PANCREAS 23 1 

Acute Pancreatitis. — This condition exhibits acute degenerative 
changes in the parenchymatous cells and an exudation into the inter- 
stitial tissue. It is often associated with cholelithiasis, and is usually 
hemorrhagic or gangrenous. In the lower animals pancreatitis may 
be produced experimentally by the injection of an artificial gastric 
juice, but it is impossible to foretell which form of the disease will 
result. Hemorrhagic Pancreatitis. — This variety of pancreatitis is 
usually associated with gastric or gastroduodenal dyspepsia, slight 
swelling of the epigastrium, and obstinate constipation. The pancreas 
is enlarged and infiltrated with blood. There is a cellular and fibrinous 
exudate present, with a necrosis of the parenchyma ; also disseminated 
necrotic foci are found in the omentum and peritoneum. This con- 
dition often ends in gangrenous pancreatitis, where the organ is en- 
larged, swollen, soft, friable, of a color varying from mottled red 
and gray to dark brown and black, and gives off a foul odor. The 
extension of the disease to the neighboring tissues may result in almost 
complete sequestration of the pancreas. In some cases it has been 
found that the organ has entirely disappeared, its place being taken 
by an abscess-cavity containing a foul-smelling mass, which may dis- 
charge through the intestine. Disseminated fat necrosis often follows. 
Gangrenous pancreatitis may be the result of a perforating inflam- 
mation of the gastro-intestinal or biliary tracts, arterial sclerosis, and" 
hemorrhagic pancreatitis. Pancreatic Hemorrhage. — The pancreatic 
vessels may rupture from trauma, or the hemorrhage may accompany 
tumors, cysts, purpura, eclampsia, and acute infections. Apoplexy in 
this organ is seldom associated with arterial disease. Extensive fat 
necrosis now and again accompanies it. Opie considers that pancreatic 
hemorrhage and hemorrhagic pancreatitis represent a single patho- 
logic process. 

Chronic Interstitial Pancreatitis. — This disease is related to dia- 
betes mellitus, is secondary to morbid changes in the intestines, the 
bile passages, and the liver, and is associated with arterial sclerosis, 
syphilis, tuberculosis, and abuse of alcohol. The islands of Langer- 
hans are frequently not affected. Chronic Pancreatitis. — In the inter- 
lobular form of this disease the gland is hard, dense, and nodular, with 
a granular surface. On section the tissue is compact and homogeneous, 
the loose areolar tissue being replaced by scar-like bands. The islands 
are unaltered, and the acini have atrophied nuclei and dilated lumina. 
Lymphoid cells are present in great numbers. In the interacinous 



232 



POST-MORTEM EXAMINATIONS 



variety the gland is tough and shows newly formed connective tissue 
in the lobules. The lesions are diffuse and irregular in distribution; 
in one place thickening of the connective tissue and of the network 
supporting the acini may occur, while elsewhere are found compact 
bands or small masses of stroma. Lobulation is observed, and at 
times is associated with general pigmentation. The change in either 
case may be only microscopic. Fatty infiltration may obscure both 
types. Chronic pancreatitis may be due to obstruction of the pan- 
creatic duct, to pancreatic or biliary calculi, to malignant growth com- 
pressing or invading the organ, to an ascending infection from the 
duodenum, to alterations of the blood-vessels, to arterial sclerosis, to 
association with chronic tuberculosis of other organs, and at times to 
alcohol and to cirrhosis of the liver. It is very rarely due to syphilis. 

Congenital Syphilitic Pancreatitis. — In this form of the disease 
the organ is enlarged and firm. There is a diffuse interstitial prolifer- 
ation of the interlobular and interacinous tissue, first with atrophy and 
finally ending in destruction of the parenchymatous elements. The 
arteries are the seat of a syphilitic periarteritis and the adventitia is 
infiltrated with lymphoid cells. Finally the capillary network around 
the acini disappears. The islands of Langerhans are not involved, but 
are surrounded by newly formed stroma. 

Hyaline Degeneration. — This attacks especially the islands of Lan- 
gerhans, and is often found in cases of diabetes, destroying the islands 
and obstructing the vascular supply of a large portion of the paren- 
chyma. Hyalin is deposited between the capillaries and the parenchym- 
atous cells. Since the islands of Langerhans are more numerous in the 
tail of the pancreas the affected areas are larger and greater in number 
in this locality and may involve two-thirds of the tissue. Epithe- 
lial cells are found arranged about a lumen, particularly at the periphery 
of the altered tissue, and show that the acini are also affected. In the 
head and body of the gland the areas are smaller and fewer. 

Fat Necrosis. — This consists of small, opaque, white areas found 
in the fat around the pancreas, which are made up of necrotic fat-cells. 
In disseminated fat necrosis small foci are widely scattered in the fat 
of the abdomen. Large foci occur, especially in the fat of the omentum. 
Both a subperitoneal and a retroperitoneal fat necrosis indicate some 
grave alteration of the pancreas. These areas are frequently sur- 
rounded by a narrow hemorrhagic zone. While these lesions are 
usually limited to the fat in the abdominal cavities, they are found, 



DISEASES OF THE LIVER AND PANCREAS 



233 



as Hauseman has observed, in the subcutaneous fat corresponding in 
location to the reddish areas visible during life upon the overlying skin. 
They are probably due to a fat-splitting ferment acting on living fat. 
Diabetes Mellitus. — A constitutional disease characterized by the 
continued excretion of large amounts of pale, cloudy urine of high 
specific gravity, containing glucose and, at times, acetone, diacetic acid, 
and beta-oxybutyric acid. It is, as a rule, associated with excessive 
hunger and thirst, and sometimes with increase in fat and at other 
times with progressive emaciation. It occurs most frequently in adult 
males, Hebrews being especially predisposed. It is due to some fail- 
ure properly to utilize certain carbohydrates in metabolism. Van 
Noorden, 1 in the Herter lectures of 1905, considers that diabetes is due 
to inability of the cells to transform glucose into glycogen and a con- 
sequent increased formation of sugar by the liver. The pancreas prob- 
ably yields some substance which affects the glycogen formed. There 
is a tendency to destructive changes in the tissues and to death from 
coma. It may be caused experimentally by ingesting phloridzin and 
by puncture of the floor of the fourth ventricle. Glycosuria is seen with 
exophthalmic goitre, certain neuroses, some diseases of the liver, cirrho- 
sis, lesions of the pancreas, injuries to the nervous system, destruction 
of gray matter in the floor of the fourth ventricle, extirpation of cervical 
ganglion, pancreatic calculi, atrophy, carcinoma, necrosis, fatty degen- 
eration, cysts, acute and rarely chronic interlobular pancreatitis. Some 
cases of the disease show an absolutely healthy pancreas, yet it occurs 
often with chronic interacinous pancreatitis. Diabetes is closely re- 
lated to destructive lesions of the islands of Langerhans, especially 
with hyaline changes and interacinous pancreatitis. In diabetes the 
number of islands may be diminished and the pancreas be nearly 
always atrophied. Arterial sclerosis and acromegaly accompany 
many cases of diabetes. It is occasionally associated with tabes. 
The cceliac ganglion is atrophic in this disease (Orth). Neuro- 
retinitis is very common, and there may be hemorrhages in the retina 
and opacities in the vitreous. The most usual change is a thickening 
and congestion of the membrane. The blood generally appears 
normal, but contains an increased amount of glycogen, and may 
be loaded with finely divided fat which floats on the surface in a 
cream-like layer. There may be lipsemic clots in the vessels. Fat 

1 Med. News, October 21, 1905. 



234 



POST-MORTEM EXAMINATIONS 



embolism of the pulmonary vessels has been described. The myo- 
cardium is pale and soft; rarely it may be hypertrophied. Advanced 
fatty degeneration of the muscular fibres is the characteristic change 
in long-standing cases of diabetes. Croupous pneumonia and broncho- 
pneumonia, chronic interstitial pneumonia, and tuberculosis are com- 
mon complications ; many of them terminate in gangrene. The lung 
may soften (malacia) and, becoming mixed with stomach secretions 
post mortem, form the so-called pneumomalacia acida. It has a sour 
but not a gangrenous odor. The spleen is usually small, pale, and soft, 
but may be enlarged and congested. Diffuse nephritis with fatty de- 
generation, and frequently glycogenic degeneration, most marked in 
the pyramids, may occur. Boils, carbuncles, onychia, eczema, and gan- 
grene of the extremities are common. The liver is usually enlarged, 
often congested, abnormally firm to the touch, and gives the glycogen 
reaction; fatty degeneration is common. Do not mistake diabetes 
mellitus for alkaptonuria; in the latter disease pigmentation of the 
cartilages or ochronosis may occur. 1 Some alkaptonuriacs do not show 
ochronosis, but thus far all the cases of ochronosis exhibit alkaptonuric 
changes in the urine. Established facts concerning diabetes : ( i ) Con- 
siderably more than one-half of all cases are due to a destructive dis- 
ease of the pancreas. (2) When due to disease of the pancreas, injury 
to the islands is responsible for the disturbance of metabolism in the 
carbohydrates. (3) Common lesions injuring the islands are chronic 
interacinous inflammation and hyaline degeneration. (4) Other le- 
sions of the pancreas do not attack the islands of Langerhans, but 
produce diabetes by destroying the interacinous islands along with the 
secreting parenchyma. (Opie.) According to the experiments of 
Sauerbeck 2 upon guinea-pigs, . total extirpation of the pancreas or 
the tying of its secretory duct gives rise to atrophy of the islands of 
Langerhans and the subsequent development of diabetes. 

The Bremer-Williamson reaction of diabetic blood may be ob- 
tained some time after death. The reaction is of special value in coma 
where urine cannot be obtained. 3 



1 Osler, Lancet, January 2, 1904, p. 10. 

2 Ergebnisse der allg. Path. u. path. Anat., 1904, eighth year, part II, p. 691. 

3 Brown, International Clinics, January, 1903, p. 266. 



CHAPTER XIII 

EXAMINATION OF THE SKULL AND BRAIN 

For the removal of the brain the body is placed in the supine posi- 
tion on the side of the table nearest the operator, with the head pro- 
jecting slightly beyond the end of the table and elevated by a block 
placed under the neck and occiput. If the cadaver be in a coffin or 
box, it may be drawn to the upper end thereof, the head being raised 
and placed upon a board laid across the top, the back supported by a 
head-rest, a block of ice, or anything else that is convenient, as a 
bundle of rags or paper. Of the various forms of support employed, 
the Cornell head-rest (Fig. 46) is peculiarly well adapted for holding 
the head steady. 

Any anomaly in the size or shape of the head is to be carefully noted. 
The scalp should be subjected to the same careful preliminary scrutiny 
for evidences of disease or injury, remote or recent, as the other 
parts of the body. It is then divided by an incision extending from one 
mastoid process to the other (Fig. 126), passing over the vertex when 
the hair is abundant and about midway between the vertex and the 
external occipital protuberance when it is thin. If the hair be long, 
it should be parted along the proposed line of incision, in order that 
as little of it as possible may be cut (Fig. 127). For the same reason 
and to guard against damage to the knife, the cutting edge of the 
scalpel or cartilage-knife should be directed from the skull when the 
scalp is being cut. In case of any previous injury to the scalp or of 
the presence of pathologic lesions the incision may have to be modified 
according to circumstances. Loose hairs should be at once removed, 
as they interfere with the sawing later on. When all the tissues overly- 
ing the skull have been separated, the scalp is reflected backward 
and forward by force, the calvarium being exposed from the occiput 
to or slightly beyond the frontal eminences. In the case of a woman 
with abundant hair, a coiffure as seen in Fig. 128 may be prepared. 
Such an arrangement keeps the hair clean and saves much time in 
the restoration of the body. The eyes and nose should be protected by 
pledgets of cotton placed beneath the anterior flap. Care should be 
taken to avoid tearing the scalp at the extremities of the incision behind 

235 



236 POST-MORTEM EXAMINATIONS 

the ears, especially if the posterior incision with a large anterior flap 
be made. Indeed, it is for this reason that the incision is begun and 
ends behind and not in front of the ears, for a tear behind the ear 
would hardly be noticed, while one in front would cause considerable 
disfigurement. The scalp may be so adherent to the cranium — a con- 
dition more apt to occur in the posterior segment than in the anterior — 
as to necessitate its removal by dissection with the knife or scraping with 
a chisel. Whatever instrument is used, guard against its slipping, lest 
injury be done to the operator or to the subject. Avoid undue traction 
of the scalp, which would cause it to present a baggy appearance when 
replaced. 

The skull should next be examined in detail. Fractures and other 
evidences of injury may now be revealed which could scarcely have 
been discovered in the preliminary examination. Note should be made 
of the presence of atrophy, hypertrophy, or softening of the bone, of 
premature or delayed synosteosis and supernumerary bones, of tumors, 
of syphilitic or tuberculous abrasions or openings, of marks of previous 
trephining, of asymmetry and abnormal coloration, of the " greenish- 
yellow" discoloration due to osteomyelitis or the " citron-yellow" due 
to tertiary syphilitic lesions, etc. (For cranial measurements and 
pathologic types of skull see Chapter XXIV.) 

There are two methods of removing the calvarium, — the angular, 
in which the skullcap is sawed in two intersecting planes meeting 
behind the ear, and the circular, in which the bone is divided in a single 
plane. The former method is usually to be preferred, as it permits 
more secure reposition of the skullcap, but, the latter is easier of appli- 
cation and will, therefore, be considered first. 

The Circular Method. — The path of the saw, which may be 
marked with a pencil or the point of a knife, traverses a plane cutting 
the skull from half an inch to an inch above the glabella anteriorly, 
an inch or an inch and a half above the external auditory meatus 
laterally, and passing just above the inion posteriorly. This line will 
cross the temporal muscles obliquely, and they and their fascia should 
be divided with a knife instead of the saw, in order that their edges 
may be accurately approximated for suturing when the skullcap is 
replaced. 

Sawing the skull is no easy task; it may be greatly facilitated by 
the employment of an electric or dental engine. For this part of the 
operation it is a decided advantage to be ambidextrous. While the 




Fig. 126.— While the right ear is held back with the left hand an incision is started directly over the 
mastoid process. The remainder of the incision over the vertex will be made from within outward, thus 
avoiding dulling the knife and cutting the hair. 




Fig. 127. — After the initial incision has been made behind the ear, the hair may be parted when it is long 
so as not to injure it when incising the scalp. 




Fig. 129.— Method of sawing the skullcap. The temporal muscle has been cut through with a knife in the 
direction of the future sawing, and a pencil mark shows the posterior line along which to saw. The hand is 
protected with a towel. 




Fig. 130.— Angular method of removing the brain. The saw markings in each case pass close to the ear and 
meet an inch or so above it. The left hand is covered with a towel to protect it from injury. 




Fig. 131. — Method of breaking up the inner table with an old knife after sawing. (There are also 
various forms of chisels made especially for this purpose.) 







Fig. 132.— Method of drawing off the skullcap with a retractor after the sawing is completed. 



EXAMINATION OF THE SKULL AND BRAIN 



237 



sawing is being done with one hand, the head must be steadied with 
the other, placed either on the vertex or on the face and protected 
by a towel, for the saw is liable to slip, especially when first applied. 
The scalp, especially of a female, should be protected from " sawdust" 
by wrapping towels about it. Rotating the head to one side will 
give considerable room on the opposite side for purposes of sawing. 
Proffered assistance should be declined, because, while it is natural to 
look out for one's own fingers, it is impossible effectively to guard 
another's. The reason I often give for not accepting aid is that " I am 
reasonably supposed to know where my hand is, but not where yours 
may be." The saw may be carried entirely through the bone or, 
better, only to the inner table, this being divided later with chisel and 
hammer. The hand soon becomes trained to the different sensations 
from sawing through the outer table, the diploe, the inner table, and the 
dura. The reddish bone-dust of the diploe is also characteristic. A 
bone-sounder, such as the surgeons use in trephining, may be employed, 
if desired. In no case, however, where it is suspected that the skull may 
have been fractured should the hammer be employed, as the force 
of the blow required might be sufficient to split the bone. While a post- 
mortem fracture may be recognized by the absence of extravasated 
blood, the enlargement of a pre-existing fracture is more difficult to 
differentiate. A receptacle should be placed beneath the head to catch 
the cerebrospinal fluid and the blood that escape when the skullcap is 
removed and the meninges are opened, and care must be taken to pre- 
vent spattering. The calvarium is loosened by twisting a chisel or the 
sharp end of a hammer in the kerf, and removed with a blunt hook. If 
instead of an instrument the fingers be used for the purpose, they must 
be well protected, as they are liable to slip and be abraded by the sharp 
edges of the bone. Traction should be made steadily and not in jerks, 
lest from a sudden giving way the calvarium be damaged by falling 
on the floor or surrounding objects be soiled by the spattering of 
blood or other fluid. When, as is sometimes the case, the calvarium 
does not readily yield to traction applied in front, it may often be 
easily detached by inserting the hook posteriorly. If the dura be 
adherent, as not infrequently happens in cases of chronic alcoholism, 
old injuries, or sunstroke, it may be loosened with a blunt instrument, 1 
or it may be divided along its margin with a pair of blunt-pointed 

1 Stroud uses a long flexible spatula. Med. News, December 9, 1905. 



2^8 POST-MORTEM EXAMINATIONS 

scissors or a curved, probe-pointed bistoury cutting from within out- 
ward, the falx cerebri being incised close to the corpus callosum. In 
children under seven years of age this must always be done, as up to 
this time of life the dura is normally adherent to the osseous structures 
of the skull. 

The Angular Method. — In this method the skull is sawed in 
two planes which by their intersection form an obtuse angle at a point 




Fig. 133. — French method of opening the skull. (After Letulle.) 

a little below and slightly posterior to the apex of the ear. Always 
try to saw above the line of the hair in front. Although this makes 
the anterior fossa deeper and consequently the removal of the brain 
more difficult, it obviates the ugly ridge on the brow so liable to be 
made by the inexperienced. It is necessary, too, that the angles be well 
sawed through and carefully broken, because if spicules of bone remain 
the brain may be caught and injured during its removal. (For this 
method of opening see Figs. 129 to 132, inclusive.) 

In the French method of opening the adult skull with a hammer, 1 



1 J. Dejerine, Anatomie des centres nerveux, 1895, p. 13. 




Fig. 133.— Appearance of the dura mater after removal of the calvarium, showing the superior longitudinal 

sinus and the meningeal vessels. 



gf& 



N'r 





Fig. 136.— Appearance of the brain after removal of the dura, which has been left attached at its 

posterior extremity. 




Fig. 137 — Method of removing the brain after it is severed from the body. 




Fig. 138.— Appearance of brain after being sawed through. Notice how even, the cerebral surface seems, just as if 

it had been cut with a knife. 



EXAMINATION OF THE SKULL AND BRAIN 



239 



the anterior and posterior flaps are made in the usual manner. A line 
one centimetre above the soft tissue is drawn around the skull with a 
soft pencil or with ink, the temporal muscles being cut through with a 
knife ; by means of blows with the hammer the skull is then fractured 
along this line. The sound tells you when the bone is fractured and 
warns you to proceed to a new place. (Fig. 133.) This method is 
much employed in France, and in the hands of experienced operators 
gives good results, though it is most difficult of performance in the re- 




Fig. 134. — French method of opening the dura. (After Letulle.) 



gion of the exterior occipital protuberance. It must not be used in 
children, in cases of fractures, bone lesions, etc. The dura is opened 
along the circular incision, or, more frequently, crucial incisions are 
made on either side of the longitudinal sinus and each side is incised 
by a perpendicular cut running from the vertex down to the upper mar- 
gin of the bone. The four pieces are then turned down and the falx 
cerebri is cut anteriorly just behind the crista galli and with a portion 
of dura on each side of the longitudinal sinus pulled backward. It 
will be seen that the dura mater thus covers the sawed portions of 
the bones (Fig. 134) and affords a protection to the hands in the 



24 POST-MORTEM EXAMINATIONS 

subsequent removal of the brain. Aseptic compresses may also be 
used for a similar purpose. 

The thickness of the skull is next noted. It varies much, being 
usually greater in negroes and, at times, in syphilitic subjects. It 
also varies in different parts of the same skull, being thinnest in the 
temporal region and thickest at the occiput, and is often unequal 
in corresponding points of the opposite sides. The diploe may be 
entirely absent in some places, in which case the bone-dust will lack 
the reddish color commonly observed in recently sawed bone. The 
skull is usually from two to six millimetres thick. In rare cases the 
frontal sinus may extend high up and be of unusual thickness ; in one 
of my subjects it measured half an inch across at the top after removal 
of the calvarium in the usual manner. Note the relations of the 
external table, internal table, and diploe. Pay especial attention to 
the amount of blood in the latter; if abundant, suspect fracture. At 
times it is entirely bloodless. The skullcap should be held up to the 
light so that any inequality in its thickness may be perceived. The 
Pacchionian granulations often give rise to small nodular depressions 
in the inner table, which are of course perfectly normal and should 
not be mistaken for pressure atrophy. They sometimes cause perfora- 
tion of the bone, or permit of the passage of an external infection into 
the interior of the skull. 

The grooves of the middle meningeal artery must be looked for 
on each side. In one of my cases of acromegaly the inner table resem- 
bled worm-eaten wood; the bone was soft and pliable and offered no 
resistance to the saw. It is necessary to be familiar with the normal 
yellowish-gray color of the inner table in order that changes in it may 
be readily detected. Whenever blood is found between the inner table 
and the dura, careful search must be made not only in its vicinity 
but also on the opposite side for a fracture by contrecoup. In the exam- 
ination of the dura mater note its thickness, the degree of distention, 
its color, which is normally gray and never very red, and the amount of 
blood contained within it. As all liquid naturally gravitates down- 
ward, those portions of the dura which cover the most dependent parts 
will be most distended, unless, as often happens, an injury of this mem- 
brane has allowed the fluid to escape. 

The arteries lie between the two veins. The larger arteries usually 
contain more blood than the veins. The dura is supplied with but 
few capillaries and these rarely become inflamed. 



EXAMINATION OF THE SKULL AND BRAIN 241 

In the examination of the outer surface of the dura mater (Fig. 
133) note alterations in color and gloss. The latter is often lost in 
consequence of tumors, hemorrhage, hydrops, abscess, and other con- 
ditions that cause increase of intracranial pressure. Search for hemor- 
rhages (which at times are profuse and depress the brain) and their 
points of origin, Pacchionian bodies (which must not be mistaken for 
tubercles), bulging tumors, and external pachymeningitis (ossified, 
purulent, syphilitic, or tuberculous), etc. The degree of tension due 
to fluid, etc., may be determined by puncturing or by pinching up the 
dura. Bone-dust from the sawing may resemble the Pacchionian bodies. 

The brain may be exposed, but not dissected, before the heart is 
incised, as the quantity of blood in the cerebrum may be modified by 
venous oozing during the examination of the thorax. If the brain 
is to be injected, it is best not to remove the dura, as by its detachment 
usually some of the veins entering the longitudinal sinus are torn, and 
this permits the escape of the injecting fluid when under pressure. It 
has been shown that this operation can be performed without external 
disfigurement while the brain is in situ by forcing the fluid through a 
cannula introduced by way of the nostrils or the orbits. 

The longitudinal sinus is opened throughout its entire length with 
a pair of probe-pointed scissors, and the condition and quantity of the 
contained blood are noted. 

The dura is divided parallel with and slightly above the sawed edge 
of the skull, with a pair of blunt-pointed scissors, which may be intro- 
duced through a chance nick made by the saw or through an opening 
made with a knife for the purpose. The incision is carried completely 
around the skull except at the poles of its anteroposterior diameter, 
where it is necessary to sever the falx cerebri. The arachnoid surface 
of the two lateral flaps of the dura may be examined by reflecting them 
to one side. The character of the blood in the membranes of the 
brain and in its cortex, the fluid in the subarachnoid space, the charac- 
ter of the sulci and convolutions, and the presence of lymph are all to 
be noted. 

To detach the falx grasp both folds of the frontal dura with the 
thumb and index-finger of the left hand, and with the right insinuate 
the blade of a knife along the outer face of the left fold of the dura 
to its attachment to the ethmoid bone. This is severed by turning the 
cutting edge of the blade inward towards the falx and detaching it 
along the line of its insertion from before backward, as near the crista 

16 



242 POST-MORTEM EXAMINATIONS 

galli as possible without injury to the olfactory bulbs. As the knife 
reaches to the anterior genu of the corpus callosum, the index-finger 
may be gently introduced into the longitudinal fissure so that a view 
may be had of the portion to be cut. It is no unusual thing to leave 
behind a thin strip of the dura just above the corpus callosum, a 
mistake which may subsequently cause annoyance to the operator or 
injury to the brain during its removal. 

The dura may now be drawn backward and cut off posteriorly or 
left in situ in order to protect the hands of the operator and the brain 
in its removal (Fig. 134 and Fig. 136). The portion of the pia mater 
dipping down to the genu and splenium of the corpus callosum may be 
detached with forceps, and that overlying the surface of the cerebrum 
with the fingers. The handling of this delicate membrane can be 
greatly facilitated by allowing a stream of water to flow gently over it 
during its removal. The pia is colorless when normal, but may be gray 
or grayish white when thickened, yellow when pus is present, or red 
from hyperemia or hemorrhage. 

The anterior extremities of the frontal lobes are gently raised with 
the bended tips of the fingers of the left hand, and any remaining shreds 
of dura are severed to prevent injury to the cerebral tissue in the frontal 
region or corpus callosum. With the handle of a scalpel the grayish 
olfactory bulbs are now shelled from the grooves in the cribriform 
plate of the ethmoid bone in which they lie, and the entire brain is 
gently turned outward while supported by the left hand. The various 
nerves (Fig. 140. The fourth trochlear is the smallest of all the nerves, 
the fifth being the largest. ) and vessels are divided, as near as possible to 
their respective foramina, with a sharp, narrow-pointed scalpel, always 
cutting towards the bone. The ophthalmic artery and optic nerve are 
now severed close to the optic foramen, first on one side, then on 
the other. Next the dura enclosing the pituitary body is cut with a 
sharp knife near to the bone (sella turcica) at all points except poste- 
riorly near the infundibulum, great care being taken not to injure the 
delicate hypophysis, which then may be shelled out and the remaining 
portion of the dura behind be excised with scissors. Or, the infundib- 
ulum may be cut, and the pituitary body removed as described on 
p. 244. The internal carotids, sometimes the seat of an embolus, are 
cut long, especially if the brain is to be injected. Next cut the common 
motor oculi, the trigeminal, external motor oculi, facial, auditory, 
hypoglossal, glossopharyngeal, and pneumogastric, and as the temporo- 



EXAMINATION OF THE SKULL AND BRAIN 



243 



sphenoidal lobe leaves the middle fossa of the skull, the tentorium cere- 
belli is divided with blunt-pointed scissors, or with a knife with a 
broad, flat back made especially for this purpose, along the superior 
border of the petrous portion of the temporal bone, preferably pass- 
ing from the median line towards the sides. In making this incision 
care must be taken not to injure the cerebellum. 

The brain mass being now supported on the left hand, cut the cord 
as low down as possible by a transverse incision. Pick's myelotome 
(Fig. 20) is a very convenient instrument for this purpose. Orth 
thrusts the knife through the centre of the cord and severs first one side 
and then the other. Any attachments of the spinal cord, medulla, and 
vertebral arteries can readily be loosened by introducing the forefinger 
into the cavity of the spinal column and through the foramen magnum. 
Of course, if the cord has already been removed, it remains only to cut 
the vertebral vessels. 

The brain is now entirely free, but the cerebellum still remains in 
the posterior fossa, from which it is best removed by holding it firmly 
to the cerebrum with the fingers of the right hand and turning the 
brain first to one side and then to the other (Fig. 137). The brain, 
with its pia and arachnoid still attached, is now weighed. A towel pre- 
viously rolled up into the form of a turban makes an excellent tempo- 
rary resting-place for the inverted brain. 

During this entire procedure, which has taken longer to describe 
than it does to perform, the secant has been searching the exposed parts 
for any lesions or abnormalities, as their presence may modify subse- 
quent processes. Thus, a tumor of the brain penetrating the middle 
ear might cause a portion of the temporal bone to be removed attached 
to the brain. 

Examine the external surface of the brain, the adherence of the 
pia-arachnoid being tested in several places, not forgetting the fourth 
ventricle, the circle of Willis, and the course of the middle cerebral 
artery lying in the fissure of Sylvius. With the latter the island of 
Reil and the retroinsular convolutions are also exposed. Should this 
membrane be adherent a portion of the cortex from which no attempt 
has been made to remove the pia-arachnoid should be saved for micro- 
scopic study. 

Sawing of Brain. — This method gives astonishingly good results, 
especially if the brain be soft, as after the body has been in water for 
some time. The sawing is done directly through the brain while mak- 



244 POST-MORTEM EXAMINATIONS 

ing the circular incision. Fig. 138 shows the smooth surface of the 
brain after this procedure, it having every appearance of having been 
cut with a knife. It will be noticed that in this instance the skullcap 
was unusually thick. Perpendicular and transverse incisions may be 
made while the brain is in situ, or it may be removed, and dissected in 
the usual manner. 

Removal of the Pituitary Body.' — In the removal of the pitui- 
tary body after that of the brain, it will be found of advantage to 
make a transverse slit on both sides of the anterior and posterior clinoid 
processes. Then with the chisel a broad incision is made transversely 
on the dorsum of the sphenoid bone about three-eighths of an inch 
below the posterior clinoid process, i.e., slightly lower than the bottom 
of the sella turcica. After these incisions have been made the small 
piece of bone is removed by pressure from above and the pituitary body 
may easily be shelled out in its entirety. (Fig. 139.) 

Quick, but not Accurate, Methods. — Some operators do not 
even take the trouble to remove the brain from the skull, but merely 
make a number of transverse incisions across the cerebral structures. 
This method is only mentioned to be condemned, though it may 
diagnose a hemorrhage, a tumor, or an abscess. 

In the Coroner's work it is often necessary to make a diagnosis 
between heart-disease and apoplexy, when, because of baldness of the 
individual or for lack of time, it is impracticable to open the head. In 
such cases I have found it feasible to trephine just above the ear and 
from this point tap the ventricles and other situations liable to be the 
seat of hemorrhage, using an instrument resembling an apple-corer to 
remove brain substance for examination, though enough clotted blood 
may be brought out attached to a long, thin brain-knife passed into 
the places where hemorrhage usually occurs — i.e., the ventricles and 
the cerebellar lobes — for the purpose of establishing a probable 
diagnosis. 

Examination of the Base of the Skull. — The base of the 
skull and its sinuses are next to be examined. Study the dura at its 
base for (1) inflammation resulting from fracture or caries, (2) tuber- 
cles, (3) gummata, (4) thrombosis of lateral sinus, (5) pachymenin- 
gitis and leptomeningitis, and (6) tumors. A fracture may be hid by 
the dura, but its situation will usually be shown by the presence of hem- 
orrhag-e. The dura must be stripped off, though this often consumes 
considerable time, so that the surface of the bone may be exposed. 







Fig. 139.— Removal of pituitary body. 




Fig. 140. — The twelve cranial nerves in situ, with the 
exception of the left olfactory nerve, which has been dis- 
placed in order to show the optic nerve. 




Fig. 141.— Dissection of the brain ; commencement of initial incision. Better to have the thumb near 
the corpus callosum and the fingers over the convexity. 




Fig. 142. — End of initial incision. 



















■F 






' ■ ■ . 




■■I Vpp ■ - 


■ 




; 'X; - 1 


■ 
£'--- f 1 


wT : IIS 


HE* a-' JhBR 
Wp-f - »J| 






"*> .«H 


w -JIB jlf — idH flH^ • -^ 


^: WKr 



Fig. 143. — Exposure of the central portions of the brain. 




Fig. 144. — Method of removing the cerebellar lobes from the pons Varolii 
and the medulla oblongata. 



EXAMINATION OF THE SKULL AND BRAIN 



245 



Unless this is done, a linear fracture — one near the foramen magnum, 
for example — might easily be overlooked. Special examinations should 
now be made of the orbit, internal ear, and nasopharyngeal cavities. 
The situation of the cranial nerves is seen in Fig. 140. 

INTERNAL EXAMINATION OF THE BRAIN. 

The brain may be sectioned either immediately upon its removal or 
after first being hardened, each method having its advantages. If an 
immediate diagnosis is required or colleagues are present to give 
unusual interest to a discussion of the findings, the sectioning will 
probably be done at once. If any hemorrhagic lesion is suspected, 
it is more conspicuous in the recent state, and a wholly unexpected 
bacteriologic investigation might be demanded by the revelations of 
the incisions. If none of these considerations prevails, the brain is 
hardened in a medium which will not interfere with any microscopic 
work that may be desired after the sectioning. Since hardening in 
certain fluids is necessary for certain stains and entirely precludes 
others, we must first of all decide what staining methods will be used 
before a choice of hardening fluids can be made. A two and one-half 
per cent, solution of bichromate of potassium or Miiller's fluid will 
develop color contrasts between the white and gray matter and furnish 
material for Weigert and Golgi work, but the later methods for gan- 
glion cells and neuroglia are precluded. Formalin is suitable for all 
special staining methods, including Nissl's, though here the best results 
are obtained when the tissues are hardened in alcohol. 

The brain may be hardened entire in a ten per cent, solution of 
formalin in a week or ten days and be suited for general topographic 
work. For finer histologic methods the parts should be serially in- 
cised, the sections being not more than three millimetres thick and 
remaining in situ, or, if the material to be studied is not superficial, 
the brain may be incised according to the methods herein to be given 
and then hardened. The advantages of hardening the brain in most 
pathologic cases are so obvious that they do not require mention. 
It should always be done unless contraindicated, and when the fresh 
brain is sectioned and examined, the incisions should be so made that 
all the segments will fold together like the leaves of a book, — unin- 
jured, undisturbed in their structural relationship, and fit for the most 
exhaustive microscopic examination. 



246 POST-MORTEM EXAMINATIONS 

Whether the brain is sectioned first or after hardening, the choice 
of a method will be somewhat determined by the situation of the 
lesion and the desire to preserve intact all its structural relations. 
Morbid changes in the cortex which we might wish to trace down 
through the internal capsule would be studied only with the greatest 
difficulty after sectioning by Meynert's method, whereas if the lesions 
were bulbar or situated anywhere in the brain-axis this method would 
be very advantageous, since it permits of examining the whole of the 
brain-axis by serial sections. 

The centrum ovale is well studied by Pitres's method, but future 
microscopic investigation is impossible. The same is true of Noth- 
nagel's method, and to examine lesions of the internal capsule we must 
have horizontal sections. For exposing suspected or unsuspected 
lesions, for gaining a good idea of the general condition of the brain, 
and for ease and rapidity of routine work, probably no method is more 
useful than that of Virchow. Unfortunately, it does not favor micro- 
scopic examination and therefore is rather sweepingly condemned by 
some authors. 

Dejerine makes a special effort so to section the brain that it may 
be sufficiently exposed without in any way interfering with future 
investigation. 

Virchow's Method. — A long, sharp knife should be used in the 
dissection, which should be kept clean and moist by frequent washing, 
so that the cut surfaces will be even and smooth. A dull knife tears the 
brain substance more or less, thus distorting the delicate structures. 

The brain is placed on its base with its occipital lobes towards the 
operator. Laying the left hand upon the left hemisphere, with the 
thumb in the longitudinal fissure and the fingers upon the convexity, 
raise this hemisphere slightly and at the same time pull it away from the 
median line so as to expose the corpus callosum. Insert the point of 
a thin narrow knife into the roof of the lateral ventricle, which lies 
immediately below the corpus callosum, well forward and two or three 
millimetres externally to the median raphe of the corpus callosum (Fig. 
141). Make a concave incision — concavity directed outward — through 
the roof back to the posterior cornu, being careful not to injure the floor 
of the lateral ventricle. Note the character and quantity of fluid 
present, which normally is perfectly clear and about three cubic centi- 
metres in amount. Connect the two extremities of the first incision by 
a second and third incision meeting at an angle of 45 degrees just 



2. * 

?? o 

O p 





Fig. 146. — Method of sectioning the cerebellum. 




Fig. 147. — The whole brain after it has been sectioned. 




Descending fornix 



Descending fornix 



Fig. 148.— Section of the brain. The lines and arrows show the position and direction of the various 

incisions. (After Nauwerck.) 




Fig. 149. — Basal ganglia, with cerebellum, pons Varolii, and medulla oblongata attached, in Meynert's 
method of dissecting the brain. The twelve cranial nerves are shown. C, cerebellum ; F, flocculus ; M, 
medulla; P. V., pons Varolii; T.L., temporal lobe ; F. Z., frontal lobe; P, peduncles; C.a., corpora 
albicantes ; C.c, central commissure ; R. I. C, retroinsular convolution ; O. C, optic commissure ; P.S., 
posterior roots of olfactory nerve ; 7, insula. (After Dejerine.) 




Fig. 150. — Sectioning of the brain. A B, incision practised by Flechsig; CD, that of Bris- 
saud; E F, that of Dejerine. The hemisphere to be incised is placed on its external surface, 
the occipital lobe towards the operator in case of the left hemisphere, and the frontal lobe for 
the right hemisphere. (After Dejerine.) 




Fig. 151.— Incisions made by Dejerine in a case of cortical lesion previous to hardening. 



EXAMINATION OF THE SKULL AND BRAIN 247 

outside the basal ganglia. In this manner the greater portion of 
the cerebral cortex on the left side will be removed away from the 
basal ganglia for future sectioning (Fig. 142). The right hemisphere 
may be turned half around and sectioned in the same way. 

The knife is then introduced into the foramen of Monro and the 
anterior fornix is brought forward, exposing the vela interposita and 
the choroid plexuses, which with the body of the fornix are carried 
back, thus exposing the third ventricle (Fig. 143) . The choroid plexus 
may be darkened by deposits of silver, and in the horse is a frequent 
seat of tumors. Then examine the corpus nmbriatum; the lyra; the 
anterior, posterior, and middle commissures ; the corpora quadrigemina, 
the pineal body, and the commencement and lumen of the iter a tertio 
ad quartum ventriculum. The pineal gland is often infiltrated with 
salts, as may readily be determined after sectioning by rubbing a small 
portion of it between the thumb and index-finger. If it be desired to 
examine the fifth ventricle, an incision is made directly in the median 
line into the septum lucidum, parallel to the corpus callosum, the 
anterior fornix being elevated by the left hand and thus put on the 
stretch. 

The crura are then severed by transverse incisions joining at about 
a right angle in the median line. The cerebellum, the medulla oblon- 
gata, and the pons Varolii are next to be removed. This may be done 
at the start, if preferred, reversing the order here given as to the other 
parts of the brain. After examining for dilated veins, tumors, and 
cysticerci, transverse incisions are made in the cerebellum on one side 
through the centre of the arbor vitae, and then on the other side. The 
cerebellum may, however, be removed before these incisions are made 
by severing the medulla oblongata and the pons Varolii and dividing 
the cerebellar hemispheres in the median line into two parts. The pons, 
the medulla, and the commencement of the spinal cord may now be cut 
transversely by incisions one-fourth to three-eighths of an inch apart, 
and all pathologic changes carefully noted, but these portions are pre- 
ferably hardened previous to examination, which is best accomplished 
by the preparation of serial sections. (Figs. 144 to 148, inclusive.) 

Both Nauwerck and Orth, before making transverse sections of 
the pons and medulla, fold the sections of the brain together as you 
would the pages of a book in order that it may be turned. Then, 
pushing the fingers of the left hand under the pons and medulla, the 
transverse cuts may be made. In case of tumors or metastatic condi- 



24 g POST-MORTEM EXAMINATIONS 

tions simpler methods may be used; thus, only one longitudinal or 
one transverse section may be made through the diseased as well as 
the healthy tissue, while the arachnoid is left intact. 

Meynert's Method, slightly modified by Blackburn. — The 
brain is placed with its base upward and the cerebellar end towards 
the operator. The cerebellum is elevated and the pia mater cut through 
above the corpora quadrigemina, around the crura, and along the 
inner margins of the temporal lobes until the middle cerebral arteries 
are reached. The Sylvian fissures are opened to their entire extent, 
the opercula are raised, and the insular lobes exposed to their limiting 
furrows. 

The apices of the temporal lobes are now elevated, and, with the 
knife held nearly horizontal, their junction with the base is cut through 
until the anterior extremities of the descending cornua are opened. 
The knife is inserted in the descending horn, and the incision is carried 
backward as far as the posterior angle of the insula, or even some 
distance beyond it, severing some of the convolutions at the posterior 
extremity of the Sylvian fissure. 

The next incision is made to separate the basal piece from the 
posterior extremities of the frontal lobes. It connects the anterior 
boundaries of the islands and opens the anterior horns of the ven- 
tricles. The incision may be a slightly curvedj transverse one, con- 
necting the anterior border of the islands; or, by a little care and a 
double crescentic cut, the exact boundaries of the convolutions may be 
followed. 

The cerebellum is now raised, the knife entered at the posterior 
angle of the island, and the incision carried along the outer limiting 
furrow until it meets the cut previously made through the anterior 
border. Care must be taken to keep the knife in the angle between the 
roof of the ventricle and the basal ganglia, to avoid injuring the latter. 
The basal piece is now lifted until the anterior crura of the fornix and 
the septum lucidum may be severed, and the basal section thereby 
completed. 

The basal piece thus separated includes the island of Reil, the basal 
ganglia, the crura, pons, medulla, and cerebellum. (Fig. 149.) 

Pitres's Method. — The lateral ventricles are exposed as in Vir- 
chow's method. The hemisphere lies on its under surface and a series 
of six transverse vertical sections are made parallel to the fissure of 
Rolando. These are called the prefrontal (five centimetres in front of 



EXAMINATION OF THE SKULL AND BRAIN 249 

the Rolandic fissure), pediculofrontal (at the front of the frontal 
convolution), frontal (ascending frontal convolution), parietal (as- 
cending parietal convolution), pediculoparietal (at the front of both 
parietal lobes), and occipital (one centimetre in front of the parieto- 
occipital fissure). Pitres's method is very useful for localizing lesions 
in the centrum ovale, but not at all adapted to studying the inter- 
nal capsule or to subsequent microscopic work. The same is true 
of the closely similar method of Nothnagel. Flechsig's, Brissaud's, or 
Dejerine's primary incision may be made, and after studying the cut 
surfaces the two parts are replaced and Pitres's cuts added thereto. 

The next method to be described, that of Dejerine, gives the best 
results of any of the methods now in vogue. 

Method of Dejerine. 1 — The brain is examined upon all its sur- 
faces to see if there be any cortical lesion. The inferior surfaces of the 
crura are carefully inspected for secondary degenerations. The cere- 
brum is separated from the cerebellum by sectioning the pons hori- 
zontally in a plane directly parallel with the inferior surface of the 
hemispheres and passing just above the great root of the trifacial. Fig. 
150 shows the direction of the incisions adopted for this purpose by 
Flechsig, Brissaud, and Dejerine. This divides the brain into two 
portions. The upper one contains the two hemispheres, the cerebral 
peduncles, and the superior portion of the pons, while the corpora 
quadrigemina is preserved intact by the obliquity of the incision. The 
lower portion contains the rest of the pons, the cerebellum, and the 
medulla. The surfaces of the section through the pons are carefully 
examined for degenerations in the pyramidal tracts, and the two hemi- 
spheres are separated after determining in which one the lesion is situ- 
ated, which is often decided by the appearance of degenerations in the 
cut surfaces of the pons. While Dejerine regards this as important to 
determine, because the corpus callosum should be sectioned as close 
as possible to the normal hemispheres, and the incision should not pass 
through the interpeduncular space, but encroach at least a centimetre 
upon the sound peduncle and corresponding portion of the pons, other 
neuropathologists object to this mode of procedure as being apt to cause 
disfigurement of the parts. 

The method of examining the hemispheres is determined by the 
situation of the lesion, — whether it is central or cortical. If central 

1 Anatomie des centres nerveux, 1895, p. 22. 



250 POST-MORTEM EXAMINATIONS 

the only degenerations that are of importance are those of the tracts 
of the internal capsule and in the region of the tegmentum (dorsal 
portion of the crus cerebri). Divide each hemisphere by a horizontal 
incision passing through the superior third of the optic thalamus, 
harden, prepare a drawing of the part, and section with a microtome. 

If the lesion is cortical the brain is sectioned by (i) a vertical 
transverse incision (Fig. 151, CD) passing just posterior to the sple- 
nium of the corpus callosum, and (2) a vertical transverse incision 
{A B) just anterior to the knee of the corpus callosum. In this way 
the hemisphere is divided into three segments. The posterior segment 
is composed of the occipital lobe and part of the parietal. The anterior 
is the forepart of the frontal lobe. The central is the largest and con- 
tains the regions adjacent to the fissure of Rolando, the middle portion 
of the temporal convolutions, the posterior portion of the frontal con- 
volutions, the basal ganglia, the cerebral peduncle, and the correspond- 
ing part of the pons. The anterior and posterior segments are hardened 
as they are, and the central segment also if the cortical lesion is exten- 
sive and deep so that the fluid can penetrate easily ; if not, a horizontal 
section (E F) is made through the superior third of the optic thalamus. 
In either event the pieces are hardened and cut with a microtome, pref- 
erably of the Gudden type. The anterior and posterior segments are 
cut vertically transversely and numbered. The central segment or seg- 
ments are incised horizontally. In this way not only can a cortical 
lesion be localized with great precision, but traces of degenerating 
fibres may be studied throughout their whole extent, which is not 
practicable by any other method. 

Hamilton's Method. — Hamilton injects the vessels of the brain 1 
as follows : The brain is freed from the dura, but not from the pia 
and arachnoid, weighed, and injected through the vessels at the base 
with Miiller's fluid or any other hardening agent desired. It is well to 
have a round stoneware jar with a lid of sufficient size, three fair-sized 
cannulas, several feet of good rubber tubing of a calibre to receive the 
ends of the cannulas, and a three-tubed " distributer." A piece of the 
rubber tubing about eighteen inches long having been firmly tied on 
one end of a cannula, its other end is tied into an artery, — viz., one 
into each carotid and one into one of the vertebrals, the opposite ver- 
tebral being securely ligated. The brain, with its attached tubes, is 

1 Text-book of Pathology, 1889, vol. i, p. 56. 



EXAMINATION OF THE SKULL AND BRAIN 25 1 

now placed in the jar, which is partly filled with the hardening fluid. 
The weight of the cannulas and tubes is taken off the vessels by sus- 
pending the tubes over the edge of the jar. Tie the other ends of the 
rubber tubes to the three arms of the distributer, and connect the com- 
mon tube with the stopcock of a tank filled with the preservative fluid, 
which can be conveniently raised or lowered at will, and is now placed 
about four feet above the brain in the jar. 

When certain that all attachments are secure, the stopcock is grad- 
ually opened, allowing the tubes to become filled and the fluid to per- 
colate slowly through the brain. Care should be taken that the can- 
nulas do not bend the arteries short upon themselves, thus occluding 
their lumina. The first fluid which passes through will be mixed with 
blood and should not be used again, but when it has become clear 
it may be used over and over. It usually runs through very quickly, 
and the tank should be refilled at least every day for the first week, 
and oftener if convenient. The brain should always be in an excess 
of the fluid and a vessel provided for the overflow. For refilling the 
tank it is best to draw some of the liquid out of the jar with a siphon, 
which will not disturb the brain or the position of the cannulas. 

A week or two will suffice in urgent cases, but the longer the brain 
remains in the fluid the better will be the hardening. Some of my 
most beautiful specimens are those which were kept in Miiller's fluid 
for five or six months. Haste and thoroughness are incompatible in 
this process. No padding should be used to keep the organ in position, 
the best and surest agent for this purpose being a plentiful excess of the 
liquid and an occasional change in its position. 

If it seems unnecessary to inject the vessels, the following method 
may more easily be carried out and gives most excellent results : An 
open jar, bucket, or wash-basin is one-quarter filled with absorbent 
cotton, and Miiller's fluid — to which one per cent, of formalin may be 
added with great benefit — is poured in until the vessel is about half full. 
The brain, after being weighed, is carefully placed in the centre of 
the vessel and more fluid is added until the organ is well covered, 
when it is placed in a refrigerator. If this be done, even though the 
arteries have not been injected or any incision made into the ven- 
tricles, there is no danger that the brain will decompose, even in sum- 
mer. On the next day the position of the brain is altered and the fluid 
changed. The renewal of the fluid can best be accomplished with a 
siphon, only a part of it being removed at one time. 



252 POST-MORTEM EXAMINATIONS 

The fluid is changed again on the third day, then every other day 
for three times, twice a week for the next three weeks, and once a 
week for the final three weeks. Remember that the jar is uncovered, 
and this allows of the evaporation of the fluid and possible spoiling 
of the specimen. The brain can then be thoroughly washed and put in 
80 per cent, alcohol, or the Muller fluid can after the fifth or sixth 
week be diluted with one-fifth alcohol, then with one-quarter, one- 
third, one-half, and finally three-quarters alcohol, where the brain can 
be kept for several months until it is transferred to the alcohol of 80 
per cent, strength. Instead of Miiller's fluid a 2.5 per cent, solution of 
bichromate of potassium may be employed. About two thousand 
cubic centimetres of a 10 per cent, formalin solution are used and 
changed every third day. 

Giacomini's Method. 1 — This is well adapted for the macroscopic 
study of the brain, but, on account of the zinc chlorid used, the tissue 
is rendered unfit for microscopic work. If the specimen is a brain 
tumor, a small portion of it may be placed in a hardening fluid for 
microscopic study and the remainder then treated by this process. 

The brain, in as fresh a state as possible, is put into the Liquor 
zinci chloridi (U. S. P.). It will be found to float at first and should 
be turned several times the first day. On the second day the pia and 
arachnoid, which until now have been useful in keeping the brain 
intact, are removed while the organ is under water or floating in the 
fluid; if allowed to remain longer, they become so adherent to the 
cortex as to be separated with difficulty and more or less damage to 
the cortical substance. The brain is left in the fluid for from six to 
ten days, then removed, well washed with water, and put in 95 per 
cent, alcohol for ten days or two weeks and next in glycerin for another 
ten days or more. After this it is placed in absorbent cotton and 
exposed to the air in a dark place free from dust. Any exudation 
should be carefully removed, and when no more appears (which may 
be in from several weeks to as many months) the surface is to be 
well coated with the best mastic varnish. 

Other Methods. — See page 377 for the preparation of brains 
with the object of preserving their natural coloration. Stroud 2 uses 
sodium acetate, 400; sodium chlorid, 350; formalin, 60; alcohol, 
ninety-five per cent., 1400; and water, 1600. 

1 Gior. di r. Ac cad. di med. di Torino, 1883. 

2 Med. News, December 9, 1905. 




Fig. 152.— Lines for removing the spinal cord and the brain, the latter 
through a small triangular occipital incision. A fi, initial incision for 
removal of the cord; CD, curved incision for the purpose of avoiding 
division of the skin above the dressed portion of the body ; E A F, angular 
incision in the occipiial bone through which to remove the brain without 
elsewhere opening the skull. 




Fig. 153.— Position of the body in removal of the spinal cord. The primary incision is being made. 

Face protected by a sponge. 




Fig. 154.— Removal of spinal cord. The primary incision has been made and the vertebral column freed 
from muscle, fascia, etc. The angle at which the saw should be held is well shown. 




Fig. 159.— Opening of spinal cord. 




CHAPTER XIV 

THE SPINAL CANAL, THE SPINAL CORD, AND THE NERVES 

The spinal cord may be removed either anteriorly or posteriorly, — 
i.e., by excising the bodies of the vertebrae through the thorax and 
abdomen freed from their viscera or by severing the laminae and spinous 
processes of the vertebrae through an incision posteriorly. The latter 
route is decidedly the more convenient and is used whenever possible. 
Generally it is best to remove the cord before the abdomen is opened, 
this being a cleaner operation, an important factor in private practice. 

The cadaver is placed prone upon the table close to the side at 
which the operator stands, with the head hanging over the end or, 
better, with a block under the chest and neck and, if desired, one 
under the lumbar region. Beginning at the external occipital pro- 
tuberance, an incision is carried along the centre of the back over 
the spinous processes to below the fourth lumbar vertebra, dividing 
all the tissues down to the bone. (Figs. 152, A B, and 153.) The 
incision is made low in order to allow for room for future manipu- 
lations, as the tissues here are thick and the future sawing is to 
be clone in a hollow, as it were. The superficial and deep structures 
are then dissected from the bones, exposing the vertebral groove 
on either side of the spinous processes. Or, after incising the skin 
over the spinous processes, insert the knife, with its back downwards, 
at the lower end of the incision and cut upwards along the 
column, keeping the blade pressed against the spinous processes. In 
this way the fibrous attachments are cut close and the vertebral groove 
is clean and free from troublesome soft tissues. The soft parts should 
be very thoroughly removed, as they would interfere considerably with 
the subsequent sawing. This can be quite well done by zigzag scraping 
with a chisel or an old knife. 

In cases of luxation, fracture, Pott's disease, etc., it may be 
desirable to remove portions of the vertebral column en masse. This 
can readily be done by the proper use of a saw after severing the inter- 
vertebral cartilages above and below the lesion. The space is then 
filled up in the restoration of the body by inserting a stick in the open- 
ing and pouring plaster upon it. 

253 



254 



POST-MORTEM EXAMINATIONS 



The canal is easily opened with Luer's rhachiotome, an adjustable, 
double-bladed saw devised for the purpose (Fig. 26). It does the work 
more quickly, but has the serious fault that it is liable to become im- 
pacted and injure the cord in its release. The same object may be 
accomplished with a single-bladed saw having curved ends (Fig. 22). 
The lamina should be sawed close to the transverse process, with the 
saw teeth held away from the spine at an angle of about thirty degrees 
(Fig. 154). Unless this direction is taken there is some danger that 
the canal will be missed or that the blade may enter it and the cord 
be injured. Orth calls attention to the fact that one can tell when 
sufficient sawing has been done by the mobility of the spinous processes. 
Other instruments which may be used are the double chisel of Esquirol, 
the knife-shaped chisel of Brunetti, and the rhachiotome and hammer 
of Amussat, the latter being much preferred in France to Luer's rha- 
chiotome, which is not approved of. If the rhachiotome is used, as the 
seventh cervical vertebra is approached, both from above and below, 
the incisions are made more and more towards the side, as the canal 
is wider here, owing to the increased size of the cord at this spot. 
After the canal has been opened in the dorsal region with the saw, 
a pair of bone-nippers is used to pry up the portions of vertebra thus 
loosened, and the dura is exposed (Figs. 155 and 156). The sawing 
can then be continued in both directions until the entire canal is opened, 
except the atlas and axis, which had better be cut with bone-forceps 
(Fig. 157). The ligaments here, as the ligamentum nuchse and the 
ligamenta flava, are very strong. In using either bone-forceps or 
pliers be very careful not to produce artefacts of the cord. The cord 
at the first dorsal vertebra is then tied with a string, so as to have the 
situation accurately determined, or the first dorsal nerve may be 
dissected out and left attached to the cord. 

The spinal cord, covered with its membranes and at times consid- 
erable fat, may now be studied in situ, after which the dura and the 
spinal nerves are divided below the cauda equina. The dura being 
elevated with the fingers or forceps and pushed to one or the other 
side, the spinal nerves are cut, with a long, thin, narrow-pointed, 
sharp knife, close to their points of entrance into the intervertebral 
foramina. (Fig. 158.) The dura at the foramen magnum can best 
be severed from the bony margin above after the brain has been 
removed. The cord may be taken away with the brain attached 
if so desired. The spinal ganglia are situated outside the dural sac and 



SPINAL CANAL, SPINAL CORD, AND NERVES 255 

are best exposed by the anterior incision as practised by Hyrtl. The 
thirty-one pairs of nerves may be extracted with the cord by cutting 
away the articular processes and gently pulling the cord, by the dura, 
to the opposite side and severing the nerve as far in the foramen as 
possible. If the cord be removed first and the brain hung down over 
the table, there may occur a peculiar hemorrhagic infiltration of the 
loose tissues around the pons. 

By making a median incision in the dura mater the cord is exposed, 
and can, of course, be removed. This procedure, however, is more 
liable to cause injury to the cord than the method given above. 

After freeing all points of attachment the cord must be very gently 
transferred to the table or tray for further examination. Study the 
dura for ( 1 ) thickness, ( 2 ) color, ( 3 ) blood ; the cerebrospinal fluid 
for (1) pus, (2) blood; and the pia for (1) expansion, (2) thick- 
ness, (3) contained blood, and (4) color. Gentle palpation may 
reveal areas of softening or sclerosis. The further manipulation of the 
part will depend upon the extent of the examination required. If the 
cord is to be preserved for future study, the dura is opened in the 
median line throughout its entire extent, the blade being inserted at 
the lower end, and transverse incisions about one inch apart down to the 
pia are made in the cord. It may be hardened at the same time and in 
the same jar as the brain by curling it around that organ; but it is 
better to suspend it by the dura, with a small weight attached, in a long 
jar, or it may be kept in such a jar lying upon its side. In summer 
the jar should be placed in the refrigerator. 

If the examination is to be completed immediately, the cord is laid 
out on the table, with its anterior surface resting preferably on a towel 
or piece of cheese-cloth, and the dura opened throughout its entire 
length as already directed. Note is made of the conditions observed. 
Much valuable information can be obtained by the macroscopic exami- 
nation, especially if a hand-glass be used and diagrams made at the 
time. Then, with a sharp, thin knife, which should be moistened with 
water after several incisions, transverse sections about an inch apart are 
made through the cord and membranes; the under surface of the 
dura, however, is left uncut, in order that the cord may be replaced 
in its entirety. A careful operator may hang the cord over the index- 
finger of the left hand, keeping it in place with the thumb, and make 
the incisions there, the dura being sufficient to protect the finger. 
(Fig. 159.) A microtome knife is admirably adapted for making 
the incisions. Areas of softening should not be incised, because of 



256 POST-MORTEM EXAMINATIONS 

the inevitable disturbance thus produced in the relations of component 
parts, Froriep's incision of the spinal cord, one long longitudinal 
incision throughout the entire extent of the cord, is severely criticised 
by Virchow. The place from which sections are removed for micro- 
scopic study may best be determined by the situation of the nearest 
nerve-roots. Coplin mounts the cord upon long strips of notched 
celluloid, one side of which is roughened for writing with lead pencil. 

Where the avoidance of disfigurement above the parts covered by 
clothing is a matter of great importance, sufficient room for opening 
the cervical canal can be obtained by making a crescentic incision from 
the centre of one shoulder to the other, with the concavity towards the 
head, and dissecting up the skin. (Fig. 152, CD.) 

Sometimes it is advantageous, especially in private cases, to open 
the canal by removing the vertebral bodies through the long anterior 
incision with the body resting on its back and elevated by a block 
placed under the back so as to render the vertebrae about to be cut as 
prominent as possible. Brunetti's chisels were devised for this pur- 
pose. After removal of the thoracic and abdominal viscera, including 
the psoas muscles, the pointed guard is inserted into the vertebral canal, 
and the instrument, held parallel with the long axis of the spinal 
column, is driven forward with a mallet, thus severing the pedicles 
and removing the bodies or anterior wall. By this method the spinal 
ganglia and nerves are rendered more easily accessible for study and 
subsequent removal. The remaining steps are about the same as 
those described for the posterior incision. 

The following simple procedure for the removal of the anterior tibial 
nerve, anterior tibial artery and vein, and portions of the muscles is 
used at the Phipps Institute of Philadelphia : x An incision about two 
inches in length is made along the outer surface of the leg, over the 
upper end of the fibula. The skin-flap is dissected back to the crest 
of the tibia, and a long, thin knife is then inserted and a section made 
the length of the skin incision close to the anterior surface of the 
fibula as far as the tibia. Two transverse cuts in the direction of the 
bone are made at either end. The portion of the tissue removed will 
be found to be composed of muscle and a portion of the anterior tibial 
nerve, anterior tibial artery, and vein on its under surface. A wad 
of cotton is placed in the wound, to take the place of the muscle 
removed and to prevent deformity, and the skin incision is sewed up. 

1 D. J. McCarthy, Med. Notes and Queries, February, 1906, p. 36. 



CHAPTER XV 

DISEASES OF THE BRAIN, SPINAL CORD, AND NERVES 

The study of neuropathology is an intricate but most interesting 
field of investigation. On the one hand, lesions such as syringomyelia 
and hemorrhage into the lateral ventricles are most easily recognized 
with the naked eye, while, on the other hand, the pathology of such 
common clinical manifestations of disease as delirium, neurasthenia, 
hysteria, neuralgia, vertigo, headache, and many varieties of insanity, 
is most obscure. Again, much that made the man, as sight, hearing, 
touch, smell, taste, speech, reflexes, thought, and the power to distin- 
guish right from wrong, disappears with death. 

There exists to-day the greatest lack of uniformity as to nomen- 
clature in diseases of the brain and cord. Thus, progressive (central) 
muscular atrophy, chronic anterior poliomyelitis, amyotrophic lateral 
sclerosis, and progressive bulbar paralysis are clinically, and to a large 
extent pathologically, one and the same, the anterior roots being 
diseased and the anterolateral tracts affected; while Friedreich's 
ataxia is hereditary ataxia, and Friedreich's disease is paramyoclonus 
multiplex. In systemic diseases it is well to remember that both the 
motor and the sensory neurons are involved. An article by Barker 
in the Journal of the American Medical Association for March 31 and 
April 7, 1906, gives an excellent account of the present state of our 
knowledge concerning the neurons. 

Acromegaly. — ■ A chronic disease of nervous origin, occurring 
most frequently in adults, and characterized by an overgrowth of the 
bones, especially those of the face and extremities, by malnutrition, 
and by impairment of the senses. Morbid changes are to be found in 
the pituitary body (hypertrophy, colloid degeneration, tumors, etc.) 
and usually in the thyroid and thymus glands. There are marked 
hypertrophy of the bones of the face (especially the maxillae) and 
osteophytic growths on the bones of the hands and feet, with exag- 
geration of the normal ridges and tubercles. The thorax is enlarged 
and kyphosis may be present. The sternum is thickened, lengthened, 
and widened, as are also the ribs and clavicles. There may be hyper- 
trophy of the pharynx and larynx, leading to marked dyspnoea. In 

17 257 



25 8 POST-MORTEM EXAMINATIONS 

one of my cases, Spiller * found a sarcoma of the pituitary body, 
which had arisen from an epilus ; in another, all the glands of the body 
appeared to be hypertrophied. I have removed post mortem the 
pituitary body through the orbit. Under acromegaly may also be 
considered osteitis deformans, an affection which causes softening 
and distortion of the long bones of the body ; hypertrophic pulmo- 
nary osteo-arthropathy, where there is antecedent lung disease and 
the bones of the skull are not involved; and leontiasis ossea, an 
overgrowth of the bones of the cranium. In micromegaly atrophy 
is found in the place of the hypertrophy of acromegaly. Fragilitas 
ossium {osteogenesis imperfecta) shows abnormal osseous develop- 
ment in which there is a marked tendency for the bones to bend and 
to break. In achondroplasia the dwarfs measure from three to 
four feet in height, the extremities being much shortened in relation 
to the other parts of the body, due to a dystrophy of the epiphyseal 
cartilage. (Osier.) Gilford's diseases — ateliosis, continuous youth, 
and progeria, premature old age — are forms of infantilism. 

Ataxia, Locomotor (Tabes Dorsalis; Posterior Spinal 
Sclerosis; Duchenne's Disease). — A chronic disease of the nervous 
system, characterized by sclerosis of the cord and brain, and by inco- 
ordination, with motor, sensory, and trophic disturbances, (a) Male 
sex. (&) Adult life, (c) Syphilis. (d) Wet and cold, (e) 
Sexual excesses, etc. (i) Spinal Cord. — Externally the meninges 
are thickened and adherent. Posterior roots (spinal ganglia) are 
atrophic and of a grayish tint. Internally sclerosis of the cord begins 
in the posterior-root zone, involving the outer layers of posterior 
columns in the lumbar region. The sclerosis gradually extends 
inward, involving successively the columns of Burdach and Goll ; when 
the process reaches the upper dorsal region, it is confined to the column 
of Goll. The cord presents a flattened appearance posteriorly, the sides 
being somewhat contracted. The diseased areas are firm, grayish or 
grayish red in color, and the whole cord is often firmer in consistency. 
Both motor and sensory neurons are involved. (2) Brain. — Changes, 
of less consequence than in the cord, may be sclerosis in restiform 
bodies, inferior peduncles of cerebellum, and certain cranial nerves, — 
the oculomotor, optic, and auditory. Atrophy, especially of the optic 
nerve, and hemiplegia may occur. Some recent writers now con- 

1 Jr. Nerv. and Ment. Dis., January, 1898, p. 42. 



DISEASES OF THE BRAIN, SPINAL CORD, AND NERVES 



259 



sider paralytic dementia to be such a disease of the brain as locomotor 
ataxia is of the cord. (3) Peripheral nerves may show degeneration 
or even neuritis. (4) In later stages occur dermopathies and arthro- 
pathies, — e.g., perforating ulcer of foot, herpes, Charcot's joint, etc. 
The essential lesion is a dystrophy attacking the peripheral sensory 
neuron. Erb 1 has found that out of a total of 11 00 cases of tabes 
there was an unmistakable history of syphilis or chancre in 89.45 per 
cent., syphilitic antecedents were probable in all but 2.8 per cent., and 
even in the last syphilis is suspected by Erb. In 96 cases of tabes 
Lesser 2 found an aneurism in 18, and speaks of these processes as the 
quartan manifestations of syphilis. Recent efforts have been made to 
show that it is not the syphilis which causes this disease, but the 
mercury used in the treatment of this venereal affection. (Wolter. 3 ) 

Caisson Disease. — A peculiar hemorrhagic affection, the result of 
a sudden reduction of atmospheric pressure, which occurs in bridge- 
builders, divers, etc., who, after working for hours under a pressure 
of two or three atmospheres, have suddenly returned to air of normal 
density. In fatal cases there is a marked destruction of nerve-tissue 
in the posterior columns and the posterior portions of the lateral col- 
umns, forming fatty detritus and compound granular cells. Free bubbles 
of nitrogen are said to exist in the circulatory system of those affected, 
and it is possible that their escape from the nervous system gives rise 
to the symptoms. 4 $ 

Chorea. — (I) Acute Chorea; St. Vitus' s Dance; Sydenham's 
Chorea. Probably an infectious disease, occurring especially in early 
life in females, and characterized by involuntary muscular contrac- 
tions of great irregularity. Most cases which come to the post- 
mortem table show ulcerative endocarditis with embolism of the cere- 
bral vessels, vascular changes, and the so-called chorea bodies, which 
consist of round or oval structureless formations, varying in size from 
that of a neuroglia cell up to tenfold its diameter. There is also 
granular change in the chromophilic elements. The basal ganglia 
and the motor and pyramidal tracts are especially affected. The 
pigmentation sometimes seen is due to the arsenic administered for 
therapeutic purposes. (II) Huntington's Chorea; Chronic Heredi- 

1 Berl. klin. Wchnschr., 1904, vol. xli, nos. i, 2, 3, and 4. 

2 L. c, no. 4, p. 80. 

3 St. Louis Courier of Medicine, February, 1906. 

4 Hoche, Berl. klin. Wchnschr., 1897. 



2 5q POST-MORTEM EXAMINATIONS 

tary Chorea. An hereditary disease appearing after the age of thirty, 
and consisting in motor, speech, and mental disturbances. This 
disease is a chronic meningo-encephalitis with atrophy of the convo- 
lutions (Facklan and Osier). (Ill) Canine Chorea. 

Compression of the Spinal Cord. — (a) Caries of the spine. 
(b) New growths, (c) Aneurism, (d) Parasites, (e) Disten- 
tion of central canal by inflammatory liquid or blood. Changes appear 
first in the white matter, the fibres of which may within six hours swell 
up and disintegrate. 

Congenital Anomalies. — Cranioschisis, rhachioschisis, hydro- 
meningocele, encephalocele, myelomeningocele, hypoplasia of different 
parts, as of the cerebellum, micrencephaly, hydrocephalus, internal and 
external porencephaly, idiocy, cretinism, micromyelia, total absence of 
parts, anomalies of distribution, and many others. 

Cretinism. — In cretinism there is a low form of idiocy associated 
with anatomic changes in the thyroid gland, as absence, hypoplasia, 
atrophy, or goitre. It is endemic in certain localities, notably Switzer- 
land. Heredity bears a causative relation. The condition usually 
appears at birth. The child is stunted and dwarfish in appearance. 
The trunk is large in proportion. The head is flat, the face broad 
and expressionless, the eyes dull and stupid, the nose flat and depressed, 
the lips thick, and the tongue large and usually protruding. The teeth 
are carious; the hair is thin, brittle, and harsh; the skin about the 
hair is dry and scurfy. The abdomen is prominent ; the legs are short 
and thick, and the hands and feet are undeveloped. The skin is yellow, 
leathery, and rough. 

Epilepsy. — Considered as due to intravascular clotting of the 
cerebral vessels, with defective and unstable nerve-cells. The most 
important changes found in the nerve-cells are: (i) A form indica- 
tive of imperfect development. (2) Retention of subcortical nerve- 
cells. (3) Either an acute form of cell change, similar to that pro- 
duced by ligature of the cerebral arteries in a dog, or (4) groups 
of darkly stained, shrunken cells, representing a more chronic change. 
Changes in the vascular system : ( 5 ) Large numbers of blood-plates 
in the blood. (6) Different forms of intravascular clotting, proba- 
bly in large measure derived from amalgamation of the blood-plates, 
but to some extent also probably due to destruction of red blood- 
corpuscles. (7) Small cortical hemorrhages, which in some cases can 
be traced to rupture of a vessel blocked up by the beforementioned 



DISEASES OF THE BRAIN, SPINAL CORD, AND NERVES 2 6l 

clot. (Turner. 1 ) In Jacksonian or cortical epilepsy the convulsions 
are localized. Starr, in two thousand cases, found one hundred and 
ninety-two with maldevelopment of the brain. 

Erythromelalgia. — In this condition there is arteriosclerotic 
thickening of the blood-vessels with diminution of their lumen (oblit- 
erative arteritis) and some involvement of the peripheral nerves. 

Hemiplegia. — It may follow : ( i ) Traumatic lesions of the 
brain and cord; (2) meningeal lesions due to hemorrhage, inflamma- 
tion, syphilis, and tuberculosis; (3) cerebral lesions due to hemor- 
rhage, softening, tumors, abscesses, and sclerosis; (4) cerebrospinal 
lesions of tabes, multiple sclerosis, and general paralysis of the insane. 
It may be due originally to : ( 1 ) Intoxication by uraemia, diabetes, 
alcohol, lead, mercury, and some carbon compounds; (2) infections 
from pneumonia, malaria, typhoid fever, puerperal fever, eruptive 
fevers, diphtheria, influenza, syphilis, and tuberculosis; (3) it marks 
some cases of chorea, hysteria, and paralysis agitans. (Church.) 

H^ematomyelia. — Hemorrhage into the cord, (a) Traumatism. 

(b) Exposure, (c) Convulsions, (d) Tumor, (e) Syringomyelia. 
(/) Myelitis, (g) The cord is usually enlarged, occasionally lacer- 
ated. The blood is generally confined to the gray matter, but may 
escape beneath the membranes. 

Hereditary Ataxia (Friedreich's Ataxia). — A form of 
ataxic paraplegia occurring in several members of the same family, 
especially in the young children, (a) More frequent in males than 
in females, (b) Cord involvement occurs first and is most marked. 

(c) There is a gliosis of the dorsal column of the spinal cord, due to 
developmental errors, (d) Talipes equinus occurs in both feet, (e) 
Lateral curvature is common. In the hereditary cerebellar ataxia of 
Marie and Nonne the cerebellum is first involved. Atrophy of the 
cerebellum has been found; in some cases no microscopic changes 
were discovered but atrophy of the cells of Purkinje. 

Herpes Zoster. — An acute hemorrhagic inflammation of the 
dorsal (posterior) root ganglia. The axis-cylinders are degenerated 
and there is actual destruction of some of the ganglionic cells. In the 
peripheral nerves even sclerosis may be produced. 

Hydrocephalus. — This condition may be congenital or acquired; 
acute or chronic; within the ventricles or subdural (external hydroceph 

1 Brit Med. Jr., March 3, 1906, p. 496. 



262 POST-MORTEM EXAMINATIONS 

alus). The amount of the fluid may reach into the gallons; its 
characteristics being those of normal cerebrospinal fluid. Lead poison- 
ing is a recognized cause, and the blue line may be found on the gums. 

Infantile Paralysis (Acute Anterior Poliomyelitis; 
Atrophic Spinal Paralysis; Essential Paralysis of Chil- 
dren). — This juvenile disease is quite probably of infectious 
origin, and is the one which gives in later life such numerous 
opportunities for the surgeon and the instrument maker to 
make useful a shrunken limb. (1) There occurs a destruction of 
ganglion-cells in the anterior gray horns of the spinal cord. (2) 
The seat of the lesion is in the part of the spinal cord supplied by the 
anterior median branch of the anterior spinal artery. (3) Cervical 
or lumbar portions of the cord are most often affected. (4) In the 
early stages the lesion is an acute hemorrhagic myelitis, with rapid 
local destruction in part or whole of the large ganglion-cells and 
degeneration of their fibres, and eventually of the muscles depending 
on them for innervation. 

Inflammation. — Any portion of the membranes of brain and cord 
or of these organs themselves may show the effects of inflammation, 
and certain organisms or their toxins brought by the blood seem to 
have a direct action upon especial portions of the nervous system. 
(I) In External Pachymeningitis the outer surface of the dura becomes 
infected as a secondary condition, as from a fracture or a middle-ear 
disease. (II) In Acute Cerebrospinal Leptomeningitis the pia and 
arachnoid of the brain and spinal cord are affected, the choroid plexus 
often being involved. Causes: (a) Acute infectious fevers, (b) 
Injury or disease of the skull, (c) Extension of disease from nose, 
ear, or Eustachian tube, (d) Pyaemia. The organisms most com- 
monly found are the Meningococcus, the Pneumococcus, the tubercle 
bacillus, the Diplococcus intracellular is, and the cocci of inflammation; 
more rarely, the bacilli of influenza and of typhoid, the colon bacillus, 
and the Gonococcus. Classification. — (a) Simple or traumatic, (b) 
Purulent, (c) Tuberculous. (1) In simple or purulent meningitis 
the membranes are thickened, the blood-vessels are dilated, and there 
is more or less exudation, which may be serous, serofibrinous, or puru- 
lent. The exudation may be so extensive as to cover up the convolu- 
tions. The inflammatory process is most marked in the basilar portions. 
It may be unilateral or bilateral. In the former the condition is due to 
extension from neighboring parts. (2) The tuberculous form of the 



DISEASES OF THE BRAIN, SPINAL CORD, AND NERVES 263 

disease is usually cortical as well as basilar. It begins as a miliary 
tuberculosis, and in the early stages exudate is not extensive. The 
ventricles also may be involved and present considerable distention 
and softening, hence the name given to this condition, of acute 
hydrocephalus; they seldom suffer in other forms of the disease. 
Cytodiagnosis may be possible. See also p. 352. (Ill) In Meningo- 
encephalitis (Chronic Diffuse or Deep Chronic Leptomeningitis) there 
is chronic inflammation of the pia mater. The membranes of the brain 
are thickened and opaque and more or less extensively adherent to the 
cortex, which is torn on attempting to remove them. The convolu- 
tions of the brain are atrophied, especially in the frontal and parietal 
regions. The gray matter may be obscurely outlined. The white 
matter is firm in consistency. The ventricles are dilated and the 
ependymse granular; frequently there are areas of hemorrhage or 
softening associated with chronic arteriosclerosis. There is an increase 
in the cerebrospinal fluid. Usually sclerosis of the posterior columns, 
with involvement of the lateral, is found. There may be an extraor- 
dinary development in the lymph connective system of the brain, 
with a parallel degeneration and disappearance of the nerve-elements 
and the axis-cylinders, and finally shrinking and extreme atrophy of 
the parts involved. (IV) Abscess. — There may be a circumscribed 
collection of pus in or upon the brain substance, with or without a 
distinct pyogenic membrane. The micro-organisms most usually con- 
cerned are the Staphylococcus pyogenes, Streptococcus, O'idium albi- 
cans, Diplococcus pneumonia, Gonococcus, Bacterium coli commune, 
of tuberculosis and influenza, and of typhoid, cerebrospinal, and other 
infectious fevers. The introduction of the organism by traumatism 
should always be most carefully searched for, while extension of the 
disease from the middle ear or mastoid cells and cranial bones, or septic 
emboli from distant foci, — e.g., abscess of the liver, ulcerative endo- 
carditis, putrid bronchitis, localized bone-disease, etc., — must be 
borne in mind. Classification. — (a) Primary (rare) or secondary 
(common), (b) Single (from extension) or multiple (metastatic). 
(c) Large (size of a walnut or an orange) or minute (then usually 
multiple). Seats. — (a) Cerebrum, usually in the temporosphenoidal 
lobe (most common), (b) Cerebellum, especially in middle-ear dis- 
ease. (1) Acute abscesses, usually about blood-vessels; are minute, 
with no definite wall; contain pus mixed with reddish debris and 
softened brain matter. (2) Chronic abscesses may be superficial or 



2 6 4 POST-MORTEM EXAMINATIONS 

deep; have a pyogenic membrane, which develops in from three to 
five weeks; pus often has a greenish tint and an acid reaction, and 
may have a peculiar odor depending on micro-organisms. (V) 
Acute Cerebrospinal Meningitis {Spotted Fever) , see p. 310. (VI) 
In Acute Myelitis the cord is swollen and soft and the pia injected. 
On incision a diffluent fluid may escape. The distinction between gray 
and white matter is often lost. Hemorrhages are frequent. Histo- 
logically, the nerve-fibres are swollen, the axis-cylinders beaded, myelin 
droplets abundant, and corpora amylacea may be seen. The ganglion- 
cells are swollen, irregular in outline, and exceedingly granular and 
vacuolated. In the removal of the cord in these cases great care 
must be taken not to produce artefacts. 

Insanity. — See such works as those of Church and Peterson 
(1905); Bianchi and Macdonald (1906); and Kraepelin and John- 
stone (1906). 

Locomotor Ataxia. — See Ataxia, Locomotor. 

Neuritis may be localized to one nerve or be general, and is 
caused by: (1) Injury; (2) Exposure; (3) Poisons, as lead, mer- 
cury, phosphorus, arsenic, alcohol, coal gas, carbon disulphid, ether 
anaesthesia, etc.; (4) Infections, such as diphtheritic, puerperal, septi- 
cemic, influenzal, gonorrhceal, typhoid, malarial, beriberic, etc. 
Transverse white lines on the finger-nails are said by Aldrich to be an 
important sign of acute arsenical neuritis. Landrey's paralysis is 
really a form of infectious neuritis. All or any of the component 
parts of the nerve may be involved, and the neuritis be of the peri- 
neural, interstitial, or parenchymatous type. The medullary substance, 
axis-cylinders, and myelin may be affected. The nerve shows the 
cardinal symptoms of inflammation, the infiltration, redness, and swell- 
ing being capable of demonstration post mortem. The study of nerve 
regeneration has recently thrown some light upon the changes found 
in neuritis. The cortical centres, nuclei, trunks, and peripheral 
portions of the cranial nerves should be studied. Thus, when there 
has been paralysis of the vocal cords, the vagus and the bulbar portion 
of the accessory nerve should be investigated. 

Pachymeningitis. — See Inflammation and Vascular 
Changes. 

Paralysis Agitans (Parkinson's Disease). — It is suggested 
by Berkeley 1 that this disease is due to a disease of the parathyroids. 

1 Med. News, December 2, 1905. 






DISEASES OF THE BRAIN, SPINAL CORD, AND NERVES 265 

Poliomyelitis, Chronic Anterior. — Slow degeneration of 
cells in the anterior horns and sometimes in the nuclei of the motor 
cranial nerves gives rise to bulbar symptoms. The degeneration 
begins generally in the lower cervical and upper dorsal nerves, with 
increased neuroglia. The muscles innervated by these nerves atrophy. 
There is a slight degeneration of the pyramidal tracts towards the. brain 
or perhaps from cortical cells 'downwards. This condition is termed 
amyotrophic lateral sclerosis. In chronic anterior poliomyelitis there 
may be degeneration of the ganglionic cells of the anterior horns only 
or of the upper motor neuron as well, when the symptoms become 
identical with the disease known as progressive muscular atrophy. 
The latter disease, where the degeneration affects chiefly the lower 
neurons, is more common than amyotrophic lateral sclerosis, in which 
both neurons are attacked. Both occur the more frequently in males 
and between the ages of thirty and fifty. Lead poisoning is a certain 
cause. Exposure, infectious diseases, rheumatism, and syphilis are 
assigned causes. For acute anterior poliomyelitis, see Infantile 
Paralysis, p. 262. 

Raynaud's Disease. — A form of vasomotor neurosis causing local 
syncope, cyanosis, and symmetrical gangrene, affecting especially the 
fingers and toes, caused by spasm and constriction of the small blood- 
vessels. 

Sclerosis. — In sclerosis of the brain and cord the connective tissue 
and neuroglia are either affected singly or conjointly. Osier considers 
the degenerative, inflammatory, and developmental forms, and makes 
anatomically the following varieties: miliary, diffuse, tuberous, and 
multiple (insular; disseminated) sclerosis. In the latter form, 
Sclerose en plaques, small, usually sharply defined, sclerotic areas, of 
a steel-gray color, are widely distributed throughout the brain and 
cord, being especially abundant about the ventricles, the central canal, 
and the basal ganglia. Microscopically there is a marked increase of 
neuroglia, the medulla of the nerves is destroyed, and the axis-cylinders 
persist. Cholesterin crystals and other forms of degenerative changes 
are seen. In Primary Lateral Sclerosis (spastic paralysis of adults) 
there is a systemic degeneration of the pyramidal tract. For Posterior 
Spinal Sclerosis, see Ataxia, Locomotor, p. 258. There is an interest- 
ing form of posterior sclerosis caused by ergot. Putnam has described 
a primary combined form of sclerosis. The posterior columns are 
first and most involved. The lateral columns, the crossed pyramidal 



2 66 POST-MORTEM EXAMINATIONS 

tracts, particularly, are also affected. Other columns may be involved. 
The anterior horns may be diseased, and softening of the cord, with 
cavity production, may occur. 

Spastic Paralysis. — (I) Of Adults. — There is a systemic 
degeneration of the pyramidal tracts, but without muscular atrophy 
or sensory disturbance. (II) Of Children {Little's Disease; 
Spastic Diplegia; Birth Palsies). — Here the condition is usually due 
10 a meningeal hemorrhage of the brain induced at the time of labor, 
though Marie suggests as its etiology the maldevelopment of the 
pyramidal tracts. Hemiplegia in children is especially due to sclerosis, 
porencephalus, atrophy, embolism, thrombosis, and hemorrhage. In 
atrophy and sclerosis a group of convolutions, an entire lobe, or even 
a whole hemisphere may be involved. The affected gyri are firm, 
hard, and atrophied, contrasting sharply with the normal tissue. They 
may be uniform in appearance or there may be nodular projections. 
In porencephalon there is loss of substance, with the formation of 
cavities or cysts at the surface of the brain. 

Syringomyelia. — Syringomyelia is a chronic affection of the 
spinal cord characterized by the pathologic formation of cavities in 
its gray matter. The cavity formation is secondary. Causes: (a) 
Embryologic malformations; then often associated with spina bifida 
and hydrocephalus and properly called hydromyelia. (b) A gliosis. 
(c) Traumatism, (d) Development of embryonal neurogliar tissue 
in which hemorrhage or degeneration takes place with the formation 
of cavities. ( I ) The central canal becomes enlarged or new cavities 
extend into the gray matter of the anterior, or more frequently the 
posterior horns. The cavity, which at times contains a bloody or 
gelatinous fluid, is most often situated in the cervical and thoracic 
portions of the cord. (2) On transverse section the cavity may 
be oval, circular, or narrow and fissure-like, or it may present the 
appearance of two or more cavities independent of each other or inter- 
communicating. (3) The cavity usually contains a colorless liquid, 
but occasionally a yellow or brown gelatinous substance, or blood and 
the products of its degeneration may be present. The- white matter 
of the cord in moderate cases is unaffected, but where the cavity is 
large and pressure from the sclerotic tissue has become great, the 
white matter is in its turn involved, being crowded to the periphery 
and more or less unable to carry on its functions. 



DISEASES OF THE BRAIN, SPINAL CORD, AND NERVES 267 

Von Recklinghausen's Disease. — This is a general fibrosis of 
the peripheral nervous system. Nuthall and Billington 1 report the 
necropsy of a case. 

Syphilis of the Brain. — See p. 337. 

Tuberculosis of the Brain. — See p. 352. 

Tumors of the Brain and Cord. — Tumors and cysts of the brain 
are of common occurrence and of the greatest variety, growing from 
membranes, periosteum, or bone. Tumors of the brain which grow 
from the bone are sarcoma, carcinoma (usually secondary), osteoma, 
and gumma; from the meninges are sarcoma, carcinoma, fibroma, 
solitary tubercle, and gumma; from the blood-vessels, gumma and 
aneurism; in the brain substance, glioma, sarcoma, metastatic and 
primary carcinoma, cysticerci, of which I have had one case 2 in which 
the clinical diagnosis of hydrophobia had been made, and echino- 
cocci. Glioma, gumma, and sarcoma are most frequent in the adult; 
solitary tubercle in the child. A tumor at the base of the brain is 
probably a gumma or sarcoma; in the brain substance, a glioma. A 
sarcoma grows rapidly and a glioma slowly. (Jacobs.) The remnants 
of the neural canal over the coccyx may give rise to a glioma, later 
giving metastases. (Mallory.) A fatal hemorrhage may take place 
suddenly into gliomatous tissue. Carcinoma of the vertebral column 
may give rise to the so-called paraplegia dolorosa. Carcinoma exerts 
a toxic influence upon the nervous system, especially when of the ulcer- 
ative type. Acervuloma, endothelioma, cholesteatoma, and cerebroma, 
a heterotopic tumor in which a portion of the gray matter embryologi- 
cally becomes occluded on the white substance of the brain, also occur. 

Vascular Changes. — The effects of the blood upon the brain 
and cord, whether normal, but in increased or deficient quantities and 
pressure, or abnormal, is most varied. Bier's treatment of certain 
affections by passive hyperemia and one of the theories explaining 
sleep, are examples of the importance of this line of study upon normal 
physiology and therapeutics. Again, Meyer 3 considers that a narcotic 
acts upon the lecithin — a fat-like substance — contained in the brain- 
cells of the sensory portion of the cerebrum, as his experiences have 
shown that the narcotic effect of an anaesthetic is as the quotient of 
its power of dissolving fats divided by its own solubility in water. 

1 Lancet, December 27, 1902, p. 1751. 

2 Phila. Med. Jr., 1899, vol. iii, p. in. 

3 Med. Notes and Queries, December, 1905, p. 164. 



2 68 POST-MORTEM EXAMINATIONS 

(I) Hyperemia of the Brain, when active, shows a congested cere- 
brum, distended blood-vessels, and petechial hemorrhages. On section 
the gray substance contrasts very markedly with the white. In 
passive congestion the veins of the cortex are distended; the gray 
matter has a deeper color and its vessels are full. The gray matter 
shows distention of the smaller veins, which on section allow their 
contents to exude as drops of blood of various sizes. Excessive 
passive hyperemia may result in cerebral oedema. (II) When the 
brain or cord is temporarily or permanently deprived of part of its 
blood-supply, a condition of ancemia exists, which may be due to: (a) 
Mechanical obstruction to the circulation, — e.g., valvular heart-lesions, 
thrombosis, embolism, or ligation of a vessel, (b) Hemorrhage. 
Classification. — (a) General or local, (b) Acute, subacute, or chronic. 
(c) Partial or complete. The membranes are pale; small arteries over 
the gyri are empty, though large veins are full. The brain substance is 
anaemic, the surface moist, few puncta vasculosa are seen, and the cere- 
brospinal fluid is increased. (Ill) Aneurism of Cerebral Arteries. — 
Classification. — (a) Single or multiple, (b) Large or minute. 
Seats. — (a) Most frequent in branches of the middle cerebral artery, 
especially those of anterior perforated spaces, (b) May be cortical. 
The aneurisms are usually very small, varying in size from that of 
a pea to a cherry-stone (seldom larger), multiple, and may resemble 
bunches of grapes. If hemorrhage occurs in basal aneurisms, the 
internal capsule and basal ganglia are injured, the lesion usually being 
extensive. On the cortex the result of hemorrhage is much less grave. 
The fatty degeneration of the media is the first change in the vessel. 
The importance of arteriosclerosis is doubtful. They have been 
regarded as herniae of the intima. (IV) In Cerebral Hemorrhage 
the most common artery to rupture is the lenticulostriate (60 per 
cent. ) . The amount of blood poured out will depend upon the calibre 
of the vessel ruptured and upon the blood pressure. The bulging 
of the hemisphere containing the hemorrhage and the flattening of 
the convolution often makes the diagnosis easy. Cerebral softening 
or encephalomalacia is due to the shutting off of the blood-supply to 
the affected area. Early the area is whitish; subsequently upon the 
return of the blood the condition of red softening is produced. Classifi- 
cation. — (a) Basilar, (b) Cortical. In basilar hemorrhage section 
of the brain substance frequently shows miliary aneurisms, which are 
seen as small dark bodies along the course of the blood-vessels pene- 



DISEASES OF THE BRAIN, SPINAL CORD, AND NERVES 269 

trating the anterior perforated spaces. Aneurism of a branch of the 
circle of Willis may be found. Endarteritis and periarteritis are 
found in the cerebral vessels. At the seat of a recent hemorrhage 
the brain has a dark-red, softened appearance, the tissue being reduced 
to a coagulated or pulpy mass of detritus. The blood may later on 
be absorbed, leaving a cyst or pigmented scar. In the cyst may be 
found hsematoidin or hsematin. Secondary softening may cause 
systemic diseases. When the hemorrhage has been extensive, the 
remainder of the brain is anaemic. The gyri are more or less flattened, 
from extravasated blood, and the sulci are indistinct. Hemorrhages 
are most common near the corpus striatum towards the outer section of 
the lenticular nucleus. They may be small and limited to the lenticular 
body and internal capsule or may break into the lateral ventricle. Ven- 
tricular hemorrhage is rare. It is usually bilateral. Meningeal hemor- 
rhage is usually caused by fracture of the skull or rupture of a blood- 
vessel. The hemorrhage may be small or large. It may be above or 
below the dura or between the pia and the arachnoid. In internal 
hemorrhagic pachymeningitis the condition is a chronic one, successive 
organized layers of blood from small hemorrhages and fibrin being 
deposited on the inner surface of the dura. I have found them espe- 
cially in alcoholics. The hemorrhage may be primary into the fourth 
ventricle. For a discussion as to whether or not a hemorrhage of 
the brain is due to violence or disease, see p. 452. (V) Hemorrhage 
into the Spinal Membranes. — Extrameningeal hemorrhage may be 
extensive without compression of the cord. Rupture of an aneurism 
into the spinal canal may produce profuse and rapidly fatal loss of 
blood. There may be little demonstrable morbid change. Intra- 
meningeal hemorrhage usually occurs in scattered areas as the result 
of acute infectious fevers. More extensive hemorrhages result from 
epilepsy, tetanus, and strychnine poisoning. Occasionally hemorrhage 
into the spinal meninges may ascend to the brain. The blood may be 
absorbed from a cyst, leaving a pigmented scar. 



CHAPTER XVI 

EXAMINATION OF THE NASOPHARYNX, EYES, AND EARS 

EXAMINATION OF THE NASOPHARYNX. 

In order to expose to view the upper air-passages, nasal, pharyn- 
geal, laryngeal, and accessory cavities, epiglottis, etc., Harke's x method 
has come into general use. If the procedure is properly carried out, 
the parts when returned to their normal position present no noticeable 
deformity, though during the examination such a result would seem 
almost impossible. 

Harke's Method. — The brain having been removed and the ex- 
amination of the skull completed, the anterior skin flap is dissected away 
from the frontal bone down to the root of the nose, while the posterior 
flap is dissected away some distance below the foramen magnum. It is 
not necessary that the primary incision of the scalp behind the ears be 
made lower than the mastoid process on each side. Next, directly in the 
median line, the skull is cleft with a small saw into two lateral portions. 
For the sake of convenience the saw markings may be divided into two 
sets (Fig. 1 60), the first starting from the front in the frontal bone, ex- 
tending down to the nasal bone, and continuing to the foramen magnum 
{A B), and the other starting at the occipital bone and extending to 
the foramen magnum (CD). The atlas and axis are sawed through 
if much room be desired. The sawed portions are now separated by 
means of a chisel and hammer, any portions of mucous membrane that 
may appear being severed with a knife or scissors. By means of strong 
lateral traction the two segments may be pulled apart, and the entire 
region down to the vocal cords will thus be exposed. It is usual to 
saw a little to one side or the other so as not to injure the nasal septum, 
thus entering into one or the other of the nasal chambers. The walls 
of the accessory cavities are readily cut away with strong scissors, and 
a plain view is obtained of the maxillary sinuses as well as the frontal, 
sphenoid, and ethmoid. Even the epiglottis and vocal cords can be 
examined by this method (Fig. 161). In order to view the parts 
better, light may be thrown in by means of a mirror. Upon the com- 

1 Berl. klin. Wchnschr., 1892, no. 30, p. 742; Virchow's Archiv, 1891, vol. 
cxxv, p. 410. Beitrdge zur Pathologie und Therapie der oberen Athmungswege, 
Wiesbaden, 1895. 
270 




Fig. 160. — Method of examining nasopharynx, eyes, and ears. The sawing for opening the naso- 
pharynx is done in the median line from the frontal bone, A, to the anterior portion of the foramen mag- 
num, B, and from the occipital bone, Z?,to the posterior portion of the foramen magnum, C. The sawing 
can best be accomplished by standing on the table directly over the head, the finger-saw being especially 
useful at the beginning and the end of the operation. E and F, lines of incisions for the removal of the 
eyes ; G, situation of the ear-ossicles ; If/land L MJVO, lines for removal of the ear-ossicles ; P and Q, 
drill-holes for saw-markings in the oval method of examining the nasopharynx. 




5 3 




■■ - 



IS 



O rt 



~ o 




EXAMINATION OF THE EYES 



271 



pletion of the examination, the two lateral halves are brought into 
juxtaposition and wired, as will be seen by reference to Fig. 162. 

Another method is to drill holes just in front of the sphenoid and a 
little behind and to the right and left of the crista galli, and then with a 
saw or a chisel make an ovoid incision extending almost to the foramen 
magnum, and remove the portion of bone which hides the nasopharyn- 
geal cavities. (Fig. 160, P Q.) Nasal obstruction may cause deform- 
ities of the upper jaw, teeth, and palate. 1 

EXAMINATION OF THE EYES. 

For this purpose a triangular piece of the orbital plate of the frontal 
bone is broken through with a hammer or chisel, care being taken not to 
injure the optic nerve in the optic foramen, the remaining portion of the 
eye and the nerve being well protected. (Fig. 160, E and F.) The 
direction of the nerve can be determined by observing the situation of 
its exposed portion, and the chiselling done a small distance on either 
side of its normal position. The pieces of bone are removed with the 
nippers and the optic nerve is carefully dissected out, its cut end being 
held with the fingers or forceps. The capsule of Tenon and the fat are 
removed, and the entire eye is excised or, if this is not permitted, an 
incision is made in the sclerotica posterior to the conjunctival attach- 
ment. This requires a very sharp knife, as the tissue is extremely 
tough. A circular incision is made around the entire eye, and the 
fundus is exposed. A piece of dark cloth or cotton dipped in ink is 
placed in the remaining portion of the eye in order to hide any dis- 
figurement, and the cavity is packed with cotton. In those cases where 
permission is given to remove the eyes, this is done as in enucleation. 

If only a macroscopic examination of the retina and other structures 
is desired, the retina may be floated out in normal salt solution and then 
separated from the choroid. If the retina is to be fixed for microscopic 
examination, the incision should be as nearly equatorial as possible and 
the fundus placed immediately in Orth's or Miiller's fluid or ten per 
cent, formalin, or fixed by exposing for three minutes to the fumes 
from a one per cent, osmic acid solution heated just to the boiling point. 
The eye is then put for twelve hours into Lindsay Johnson's mixture : 

Potassium bichromate, two and one-half per cent 70 parts. 

Osmic acid, two per cent 10 parts. 

Platinic chlorid, one per cent 15 parts. 

Acetic or formic acid (to be added just before using) 5 parts. 

1 Collier, Lancet, October 18, 1902, p. 1038. 



2J2 



POST-MORTEM EXAMINATIONS 



The gloss of the cornea disappears as soon as death comes on. 
After twenty-four or thirty hours, and often earlier, the bulbus softens 
and the cornea and retina become dull. The conjunctiva is now re- 
moved more easily from the cornea, and the sclera which is not covered 
by lids becomes brownish black and dry. (Orth.) According to 
Runge, several days after death a diffuse redness occurs in the trans- 
parent media of the eyes of a fcetus that has died in utero. The redness 
affects first the cornea and then the lens, — extending from without 
inward, — in this way indicating approximately the date of death. 

The position of the eye may be altered. Exophthalmos, or pro- 
trusion of the eye, may be caused by a retrobulbar tumor, oedema, 
hypertrophy of fat, collection of blood from hemorrhages, emphysema, 
inflammatory exudates, Basedow's disease, etc. Enophthalmos, or 
retraction of the eye, may take place in atrophy of the fat, loss of liquid, 
as in cholera, deformity from scars, etc. The consistency of the eye 
varies, being increased in glaucoma and diminished in certain forms 
of degeneration. Frontal empyema may occur. 

EXAMINATION OF THE EARS. 

A fair idea of the condition of the middle ear may be obtained 
simply by chipping away the roof with a chisel or snipping it off with 
bone- forceps, but if a closer inspection is desired the petrous portion 
of the temporal bone and the mastoid process had better be removed 
together. 

Extend the incision from its original point back of the ear and along 
the anterior border of the trapezius about half-way down the neck. 
Reflect the flaps with their soft tissues so as to leave the bone clear. 
Begin at the apex of the petrous portion of the temporal bone and with 
a chisel laid flat break through the petrobasilar suture to the jugular 
foramen, and chisel or saw through the skull on a line from the jugular 
process of the occipital to a point about five centimetres posterior to 
the base of the mastoid process. Anteriorly chisel or saw through the 
skull on a line from the apex passing posterior to the spinous process 
of the sphenoid; or between the foramen ovale and the foramen 
spinosum and well anterior to the external meatus, just cutting off the 
root of the zygoma. 

Woodhead 1 uses the following method : 

" The temporal bone, with its petrous portion containing the in- 
ternal ear, may be taken out and examined after removal of the brain, 

1 Practical Pathology, 1892, p. 28. 



EXAMINATION OF THE EARS 



273 






by stripping off the dura mater from the base, dissecting off the skin 
and muscle, detaching the external ear from the bone, and disarticu- 
lating the jaw; then, taking the margins of the temporal bone as the 
base of a pyramid, the apex of which is a little beyond the inner 
extremity of the petrous portion, two saw-cuts are carried almost 
vertically downwards so as to bound the pyramid, and then with a 
bone-chisel and mallet the whole temporal bone may be removed, after 
which it may be softened in a decalcifying fluid; or the internal ear 
may be dissected out with a small saw, a pair of sharp, well-fitting bone- 
forceps, and a sharp gouge and chisel. The internal ear or tympanic 
cavity and mastoid cells may also be opened up with the aid of the 
above instruments." 




Fig. 163.— Wire-saw used in removing the auditory apparatus, the lower jaw having first been 
removed. (After Letulle.) 

By sawing or chiselling as in Fig. 160, K J I or L M N O, the ear- 
ossicles and internal ear may readily be reached. The method of 
using the wire-saw is seen by referring to Fig. 163. In this illustra- 
tion is also shown what is known as the T incision, which consists in 

18 



274 POST-MORTEM EXAMINATIONS 

making a second incision at right angles to the one across the vertex 
of the skull, thus passing through the occipital protuberance. Or it 
may be considered as a continuation of the median incision of the 
back in the removal of the spinal cord to the incision going across the 
skull. The flaps thus produced are then dissected away from the 
underlying part, and salivary glands, exocranial sinus, mastoid process, 
articulation of the jaw, intercarotid bodies, etc., examined with ease. 
A study of fifty-four mixed tumors of the salivary glands has recently 
been made by Wood. 1 The parotid gland may be the seat of primary 
tuberculosis. Salivary calculi are sometimes found. Robery, in a 
paper read in 1904 before the Chicago Medical Society, gives an excel- 
lent bibliography of this subject. Tumefaction of the parotid gland, 
with or without suppuration, coeliac or splanchnic (Sclocum) parotitis, 
may occur subsequently to an abdominal or pelvic operation. 

1 Ann. Surg., 1904, January, p. 57, and February, p. 207. 



CHAPTER XVII 

BONES AND JOINTS * 

A complete autopsy ends with a careful inspection of such 
portions of the osseous system as may need to be investigated and 
have not come under observation in those parts of the body already 
studied. Unfortunately, a thorough examination of the bones and 
joints cannot always be attempted on account of the unavoidable dis- 
figurement it entails. However, by ingenuity in technic and skill in 
restoration of the body even the removal of large portions of the skele- 
ton may be successfully concealed. The X-rays have done much in 
recent years to facilitate the study of both normal and abnormal osseous 
structures, and may often be employed to great advantage at the post- 
mortem, as in showing the exact location of a bullet. The time 
required for exposing the photographic plate to the Rontgen rays seems 
to be longer than in the examination of the living subject. 

Arthritis. — Inflammation in a joint begins either in the synovial 
membrane or in the bone, and affects all the structures of the joint 
(panarthritis) and, often secondarily, surrounding parts (periar- 
thritis). It may arise from trauma, infection, as a sequel of pyaemia, 
erysipelas, gout, gonorrhoea, tuberculosis, syphilis, scarlatina, dysen- 
tery, typhoid fever, pneumonia, or measles, or as secondary to bone dis- 
ease. It may be gouty, purulent, ulcerative, ankylosing, infective, 
syphilitic, tuberculous, etc. Lipomatous, fibrous, and cartilaginous 
growths may occur in a joint. Rice-bodies probably arise from hyaline 
portions of the synovial membrane. 

Acute arthritis consists in inflammation of the synovial membranes 
and fringes, at times with hemorrhagic extravasations, and distention 
of the capsule by effusion, in which float flakes of fibrin. The soft 
parts around the joint are swollen. The serous and serofibrinous forms 
usually terminate in resolution, without marked changes. The fibrin- 
ous form frequently results in the formation of more or less extensive 
adhesions. Empyema of a joint, arthropyosis, being generally asso- 
ciated with osteomyelitis due to metastasis from other foci, occurs 
usually in the knee, involving later many other joints. The synovial 

1 Based on the text-books of Ziegler and Green. 

275 



276 POST-MORTEM EXAMINATIONS 

membrane and the articular ligaments become dark red in color, 
swollen and infiltrated, and covered with pus; later the cartilage and 
lastly the bone (molecular necrosis) are attacked, often causing dis- 
articulation of the ends of the bones. Perforation may be primary or 
secondary. A purulent effusion, remaining a long time without serious 
destruction, is called catarrhal synovitis. 

Chronic Inflammations. — Chronic articular dropsy (hydrarthrosis) 
is a serous or serofibrinous inflammation, usually seen in the knee, 
wrist, or elbow. The synovial membrane is thickened, indurated, and 
may have patches of fatty degeneration. In the knee the patella may 
be lifted and the bursas distended by a thick or thin or gelatinous secre- 
tion, and the synovial membrane may protrude through the fibrous 
bands of the capsule. The synovial tufts become large and projecting; 
the joint-cartilages degenerate and proliferate. Adhesions or destruc- 
tion of the joint may follow. 

Chronic purulent arthritis is usually associated with tuberculosis 
or is due to extension from adjoining parts. The capsular ligaments 
and synovial membranes are infiltrated and covered with fibropurulent 
deposits ; the cartilages are cloudy, fibrillated, or necrotic, the marrow 
suppurating, and the joint filled with pus or numerous abscesses form- 
ing around the joint. Ankylosis or dense, fibrous adhesions are found 
in cured cases. 

Chronic, dry, ulcerative arthritis occurs in old age, accompanying 
neuropathic disorders, or as a sequel to rheumatism. It consists in a 
proliferation of the synovial membrane, forming fringes, and in scle- 
rotic thickening of capsule and ligaments. Fibrillation and cleavage 
of the cartilages, with patches of calcareous, amyloid, or fibroid degen- 
eration, may occur. The denuded bone of the articulating surfaces 
may ulcerate or become sclerotic and waste, the capsule becoming so 
large that dislocations may occur. In the senile form the hip is usually 
affected, but the shoulder, elbow, phalangeal joints, and the patella of 
the knee may be involved. In tabes dislocations are very common in 
knee, shoulder, and elbow. 

Arthritis deformans, chronic gout, or rheumatoid arthritis, is a 
chronic disease of the joints, characterized by degenerative changes in 
the cartilages and synovial membranes, by periarticular formation of 
bone, and by great deformity (Osier). It is often associated with infec- 
tious diseases, as gonorrhoea, gout, and rheumatism. In all forms the 
articular surfaces are hyperplastic and softened. Later, absorption 



BONES AND JOINTS 277 

takes place, the ends of the bones becoming eburnated and polished; 
the head of the femur has entirely disappeared; generally it becomes 
conical, flat, or broad. The bone marrow liquefies, forming cysts; 
subchondral cysts and deep-seated bone cavities occur. At the edges, 
where the friction is less, irregular nodules (osteophytes) develop and 
calcify. Capsules, synovial membranes, fringes, and ligaments thicken 
and become infiltrated with lime salts. There is always a complete 
absence of uric acid. Great deformity, not infrequently ankylosis and 
dislocation, occurs. There is often marked atrophy of both bones and 
muscles. Arborescent lipomata are found. The smaller joints of the 
hands and feet are usually first affected, the fingers being deflected to 
the ulnar side. In severe cases all the joints may be more or less 
involved. In old people the disease is apt to attack the hip, knee, 
shoulder, or spine. Spondylitis deformans is due to the formation of 
osseous bridges between the vertebrae. Heberden's nodosities, a form 
of the disease, consist of small nodes or tubercles about the dorsum 
of the phalanges ; this form very rarely affects large joints, as the knee. 

Gouty arthritis is the deposition of urates in the articular structures, 
usually in the metatarsophalangeal joint of the great toe (podagra) or 
a finger- joint (cheiragra). The periosteum, tendons, ligaments, and 
skin are more or less inflamed. The joint contains a clear fluid, with 
crystals of sodium urate, sodium chlorid, calcium carbonate, and cal- 
cium phosphate ; hippuric acid and other uric-acid compounds. Chalky, 
mortar-like, nodular masses, tophi, are found in the matrix of cartilage 
and ligaments. In old cases these are also found in the bone, peri- 
osteum, tendons, and bursas. Fibrillation and erosion of the cartilages 
cause abscess-like cavities, which may open externally. 

Gonorrhoea! arthritis occurs in one knee-joint, between the third 
and the sixth week of the disease. It has also been seen in an ankle 
and hip. There is a fibrous metaplasia, also a fibrous or osseous 
ankylosis. Ulceration of the cartilage, bone, and capsular tissue may 
occur, as a rule, with a purulent effusion. 

Rheumatic arthritis occurs in several joints at one time, generally 
in the hip, shoulder, and jaw. It begins as a hyperaemia of the synovial 
membranes, with an increase of fluid, followed by thickening and 
elongation of the ligaments and later by absorption or ossification of 
the interarticular cartilages, which become rough, fibrillated, and often 
converted into a tough, felted mass. Finally, there are induration and 
eburnation of the bony extremities. It may involve joints in succes- 



278 POST-MORTEM EXAMINATIONS 

sion, and, in rare cases, all the joints. It always causes ankylosis, by 
fibrous adhesions of the ligaments and bony deposits in and around 
the joint. 

Chronic ankylosing arthritis is the most common anatomic feature 
of chronic rheumatism, and is due to a vascularization and fibrous 
metamorphosis of the articular cartilages, with coherence of the opposed 
cartilages. 

Spinal or neurogenous arthritis, usually associated with tabes dor- 
salis, syringomyelia, degeneration of the anterior horns of the gray 
matter, arising from section of spinal nerves, consists in a rapid 
destruction of the articular ends of bones, thickening and ulcerative 
destruction of synovial membranes and ligaments, and a serous effusion 
into the joint, with swelling of the surrounding tissue and spontaneous 
dislocation. 

Syphilitic and tuberculous arthritis are described elsewhere. I have 
had one case of pneumococcal arthritis of the knee, with streaky hyper- 
emia of the skin, boggy swelling, purulent infiltration, and hemor- 
rhagic effusion. Toxic arthritis, due to alcohol, occurs, usually in 
small joints, and always associated with enlarged liver, spleen, and 
lymphatic glands. (Quinquaud's sign.) 

Degenerations generally occur in the cartilage of a joint. After 
hemorrhage into a joint, hsematoidin is often found as crystalline and 
amorphous masses in the superficial cells. Ochronosis produces diffuse 
brown patches in cartilages, due to saturation of the matrix with some 
unknown coloring matter. Mucoid degeneration of the matrix pro- 
duces a turbid fibrillar appearance, which may go on to complete dis- 
integration, and is often associated with fatty change in the cells. 
Fatty degeneration, a translucent gray material, appears, in senile 
softening, associated with calcification; and in chronic inflammatory 
disease. It attacks mainly the costal cartilages, but may occur in 
margins of the articular cartilages, and in places where the matrix is 
already in a process of fibrillation and degeneration. Hyaline and 
amyloid degenerations occur in the capsules and cartilage-cells. Amy- 
loid degeneration may also affect the matrix. 

Atrophy. — Acquired or true atrophy is: (i) eccentric, the bone 
being normal in size, but on section showing great increase in the 
cavities and in the amount of the cancellous tissue, and decrease in the 
compact tissue ; ( 2 ) concentric, the bone being slender and the external 
compact tissue showing local defects (osteoporosis), or being exces- 



BONES AND JOINTS 2 yg 

sively thin and brittle (osteopsathyrosis, fragilitas ossium). The med- 
ullary canal is always contracted. 

Atrophy may follow trauma, such as fracture, luxation, or epi- 
physeal injury, and disuse, as seen in old stumps and unset fractures. 
Pressure often thins the bones markedly. In hydrocephalus the inter- 
nal surface of the skull may be rough, or the inner table may be entirely 
absorbed. The Pacchionian bodies often make deep pits in the tem- 
poral bones. The vertebra, sternum, and other bones may be found 
deeply eroded and perforated by aneurisms and tumors; even scars 
may cause atrophy of the bone upon which they make pressure. 
Tumors of the marrow, periostitis, and osteomyelitis also cause atrophy 
of the bone by their pressure. A peculiar type of atrophy is seen in 
the aged, affecting those bones with only a slight muscular covering, 
as parietal, maxillary, and pelvic bones. The external table of the 
skull may be entirely resorbed. Perforation of the entire thickness 
has occurred, bony deposits being often found at the same time on 
the inner table. The bone is rough, dull, and lustreless, with shallow 
erosions, not uniform in shape or position. Nervous diseases (neuro- 
pathic and neuroparalytic), infantile paralysis, inflammation, rickets, 
and many other pathologic conditions are often associated with osseous 
atrophy. 

Chondritis. — This affection is often a sequela of severe arthritis; 
it usually occurs in articular cartilages, which become turbid and dis- 
integrate. Erosions, caries, and more or less extensive necrosis are not 
uncommon. Hypertrophic proliferation, general or local, may occur 
with any productive inflammation of the cartilage or fibrous tissue of a 
joint. It is common in arthritis deformans and tuberculous arthritis. 
In cartilage it is nodose or tuberculous, while in the capsule or synovial 
membrane it appears as a diffuse thickening or as a papillary ex- 
crescence. Loose bodies, usually found in the knee, elbow, and wrist, 
rarely in the hip, shoulder, elbow, or ankle, may be single or numerous, 
a knee with 1047 °f these bodies having been reported. These may be 
entirely free or attached by a slender stalk. They may be composed 
of fibrin, the remains of hemorrhage into the joint, or may be a pro- 
liferation of the synovial or fatty tufts, pieces of bone or cartilage 
detached by violence, foreign bodies which have penetrated the bone, 
loosened nodular masses, cartilaginous, osteomatous, fibrous, lipoma- 
tous, or lipoma-arborescent, or displaced semilunar cartilages. Bodies, 
often faceted, are usually oval, lenticular, or devious in outline. 



2 8o POST-MORTEM EXAMINATIONS 

They are associated with arthritis deformans and rheumatoid arthritis, 
and in many cases appear without signs of previous inflammation. 

Dislocations of the semilunar cartilages are due generally to sepa- 
ration of the anterior attachment of the cartilage from the tibia, which 
may be torn transversely through the edge of the meniscus or split 
longitudinally. A central tear has also been described. Cartilages, 
infrapatellar pad, and ligamentum alare are usually thickened. The 
displacement is inward, towards the centre of the joint, so that the 
leg cannot be extended. 

Fractures and Dislocations. — Fractures, the most common 
injuries to bones, are either complete or incomplete. A certain amount 
of repair callus will be found in all cases. Contiguous bones, as tibia 
and fibula, may coalesce during repair and lead to a synostosis. In 
cases with great displacement, with soft parts between the fragments, 
with existing debility or other unfavorable conditions, there may be no 
union, or simply a firm, fibrous adhesion (syndesmosis), or a false 
joint (pseudarthrosis). Compound fractures, affording a favorable 
opportunity for the introduction of pyogenic organisms, are often 
associated with caries, necrosis, or osteomyelitis. 

Diastasis, a pathologic separation of the epiphysis from the di- 
aphysis, occurs usually as a sequela of accident or ulceration, the 
epiphysis being pushed off by the resulting granulations. It is most 
common in the upper part of the femur, in the lower portion of the 
humerus, and in the tibia. In rare cases the dislocation may take place 
between the manubrium and the gladiolus, or the head of the femur 
may be found loose in the acetabulum. 

Congenital dislocation of hip, single or double, is associated with 
softening of ligaments, effusion, fungous synovitis, hydrarthrosis, 
caries, arthritis, and arrest of development. The acetabulum is nar- 
rowed, elongated, less concave than normal, and occasionally filled with 
fat, connective tissue, or exostoses. The head of the femur is flattened, 
but larger than the acetabulum ; it lies on the dorsum of the ilium or 
obturator foramen ; the neck may be wanting ; or it may be atrophied. 
If the patient has walked, there is usually a depression of the ilium 
and some lordosis. The gluteal muscles are contracted, , the unused 
muscles atrophied, and the pelvis is contracted above and expanded 
below. Congenital luxation of the sternum has been reported. If 
acquired dislocations with rupture of the capsule, tendons, ligaments, 
muscles, and other structures around the joint be not reduced, the 



BONES AND JOINTS 2 8l 

muscles and ligaments may atrophy, the synovial fluid be destroyed, 
and the bone be partially absorbed, or the bones may unite by firm, 
fibrous, cartilaginous, or bony adhesions (ankylosis). This may also 
follow non-use of a part, articular disease, trauma, phlegmonous ery- 
sipelas, burns, or as a sequela of tuberculous, gonorrhceal, gouty, rheu- 
matic, syphilitic, neurotic, or puerperal affections. A form of anky- 
losis of the spine is sometimes seen in typhoid fever. Congenital 
ankylosis of the entire skeleton has occurred. False ankylosis is due 
to bands of cicatricial tissue, adhesions of the ligaments and capsule, 
or organization of inflammatory deposits. 

Injuries. — Cuts, gunshot wounds, and stabs may result in acute 
inflammation, effusion of blood, empyema, ulceration of articular cap- 
sule, necrosis of cartilage and bone, or a more or less complete disor- 
ganization of the entire joint. Septicaemia and pyaemia may supervene. 
Crushing injuries to joints almost always end in abscess, usually asso- 
ciated with bony or cartilaginous fragments, which remain as foreign 
bodies in the joint. 

Marrow. — The marrow in children is soft, bright red in color, and 
rich in cells and blood-vessels. In middle life there is an increase in 
fatty tissue, giving a yellow or yellow-red color of oily lustre, while in 
old age it atrophies, becoming gelatinous, with clear, mucinous fluid, 
and there is a diminution of fat and a decrease in the number of cells 
present. This atrophy may follow chronic emphysema, phthisis, 
chronic disease of the kidney, or starvation. Lymphoid marrow is 
gray red or dark red, according to the amount of blood it contains. 
In pernicious anaemia the marrow of the long bones resembles rasp- 
berry jelly, while in leukaemia it has a flesh-pink to a gray-yellow color, 
like that of pus. Fatty degeneration occurs in the cells and capillaries 
of the marrow, sometimes with necrotic foci, in cases of typhoid, 
typhus, and relapsing fever. 

In osteomyelitis there is often a purulent inflammation, frequently 
complicated by transformation of the marrow into a vivid red, tough, 
fibrinous material, and with effusion into the cavity of a joint. 
Necrotic changes in the bone follow. Hypertrophy of the marrow- 
cells is seen in oligaemia, leukaemia, chronic pulmonary tuberculosis, 
chronic suppurative osteitis, cancerous cachexia, typhoid fever, croup- 
ous pneumonia, septic affections, acute endocarditis, and smallpox; 
while hypertrophy of the fatty tissue occurs in cases of general atrophy 
of the skeleton, sometimes involving the entire bone. 



282 POST-MORTEM EXAMINATIONS 

Necrosis. — Necrosis arises as the result of shutting off of the 
blood-supply. It follows infective embolus, injury, poisoning, as from 
phosphorus, and as a sequela of scrofula and the infective fevers. 
Caries, necrosis superficialis, or erosion is, as a rule, circumscribed, but 
may be diffuse or phagedenic. It occurs in the cancellous extremities 
of a bone, usually in the tibia, femur, humerus, phalanges, skull, lower 
jaw, clavicle, and ulna, and affects the joints secondarily. It is always 
associated with periostitis, osteitis, or osteomyelitis. It is generally 
dry and anaemic, but in cases of sudden onset may be moist. The 
bone is ulcerated or worm-eaten in appearance, with numerous hollows 
or cavities. It is porous, very fragile, and of a dirty-yellow, dark-gray, 
or brown color. The surrounding bone is usually indurated and hard, 
except in strumous cases, where it is converted into a mass of fungous 
granulations. The compact substance is softer and the marrow spleni- 
fled. Dead bone may be thrown off as an exfoliation or as a seques- 
trum. Panaricium, or felon, is one of the most common forms of 
periosteal necrosis, the digital skin having been injured or infected. 
Diffuse necrosis, necrosis centralis, usually attacks the shaft. There 
may be caries of the superficial bone with a narrow channel leading 
down to a focus, or an abscess in the centre (chronic sinuous abscess), 
or it may be entirely internal. Abscesses are most common in the 
articular extremities, but may occur anywhere. Swelling of the skin 
and periosteum always accompanies necrosis. The periosteum may 
retain its vitality, producing a sheath of new bone around the seques- 
trum, the involucrum, through which holes (cloacae) form for the 
discharge of dead bone or pus ; or the sequestrum may be surrounded 
by old bone or by exudate from the inflamed periosteum, the pus 
making its way through the thickened periosteum and discharging on 
the surface through several fistulae or sinuses. Phosphorus necrosis, a 
purulent periostitis, attacks especially the jaw-bone, rarely the other 
bones of the face. At first there is a slight periosteal inflammation, 
then proliferation with formation of new bone, the maxilla becoming 
thick and sclerotic ; later, suppuration leads to necrosis and exfoliation, 
at times destroying the entire bone. The infective granulomata, tuber- 
culosis, syphilis, leprosy, glanders, and actinomyces, produce chronic 
inflammations with deposition of osteophytes. The resulting necrosis 
is described under these diseases. 

Orthopedic Deformities. — Genu valgum (knock-knee), a uni- 
lateral or bilateral displacement at the knee-joint, occurs in cases of 



BONES AND JOINTS 283 

rickets or in men who have lived laborious lives. The external articu- 
lar surface of the tibia or femur is retarded in its growth or depressed, 
so that these bones form with each other an obtuse angle. This may 
be associated with separation of the epiphysis, caries of the external 
condyle of the femur, or arthritis deformans. 

Club-hand, hallux valgus, club-foot, talipes varus, talipes valgus, 
talipes equinus, talipes calcaneus, talipes cavus, and talipes planus are, 
as a rule, due to perverted development of tendons. 

Contractures are associated with poliomyelitis, caries of the spine, 
and trauma of the cord or peripheral nerves. They are the result of 
fixation of a joint in a deformed position, the character depending upon 
the group of muscles paralyzed. Dupuytren contracture is a scar-like 
contraction with fingers flexed, due to trauma, rheumatism, or gout, 
affecting the palmar fascia. Small, hard, nodular fibromas are found 
along the course of the contraction. Late in the disease the skin is 
affected. 

Spinal curvatures are associated with pleural effusion, large tumors, 
unilateral contraction of the thorax, cirrhosis of the lungs, oblique 
fixation of the pelvis, rickets, tuberculosis, weakness of the muscles, 
occupation, etc. According to Bradford and Lovett, scoliosis, or lateral 
curvature, is most common in the thoracic region, usually to the right, 
with compensatory curve, in the lumbar region, to the left. Kyphosis 
may be a rotated lateral deviation or a result of disease, as tuberculosis. 
It forms a posterior protrusion of the vertebral spines ; if due to rota- 
tion, it is usually to the convex side. The vertebrae become wedge- 
shaped. Ossification of the ligaments is at times found. Lordosis is 
always associated as a compensatory curve. Synostosis, or ossification 
in a situation not normally ossified until advanced life, causes a marked 
deformity, especially of the pelvis, shortening in the base of the skull, 
craniostenosis, microcephalia, etc., and depressions of the bridge of 
the nose. 

Osteitis is almost invariably associated with periostitis. It may 
follow trauma, such as fracture, amputation, and gunshot wounds ; or 
infections, as pyaemia, scarlatina, measles, typhoid and relapsing fever, 
dysentery, smallpox, mumps, gonorrhoea, and acute articular rheuma- 
tism. Four forms of osteitis exist: (1) Rarefying (osteoporosis), a 
chronic form associated with wounds, syphilis, or tuberculosis, which 
consists in resorption of the spongy bone, with the formation of cavern- 
ous excavations. (2) Osteosclerosis, a reparative reaction, occurs in 



2 8 4 POST-MORTEM EXAMINATIONS 

the same diseases and consists in the eburnation of the entire bone. 
(3) Osteo-arthropathy (hyperplastic osteitis), associated with chronic 
tuberculous lung diseases, involves the terminal phalanges, which 
are swollen like drum-sticks, with their articular ends irregularly 
thickened; it is also seen in rhachitis, osteomalacia, and osteitis de- 
formans. (4) Osteitis caseosa is always tuberculous. Purulent osteitis 
may follow typhoid, scarlatina, measles, and pyaemia, and is usually 
due to a secondary staphylococcic or streptococcic infection. It arises 
spontaneously in the femur and tibia; it is in almost every case asso- 
ciated with osteomyelitis, and at times with gangrene. 

In osteitis deformans we have an inflammatory disease of old age, 
consisting in a wide-spread absorption of the bone and the deposition 
of new bone. It may be limited to the femur, cranial bones, or spine, 
or involve the greater part of the skeleton. The resorption is marked 
in the cancellous and cortical regions, where the osseous trabecular 
may be replaced by gelatinous or fibrous tissue. This softening allows 
the long bones to bend at abrupt angles and gives rise to many deformi- 
ties, of which kyphosis is the most frequent. Cysts are often found. 
The deposition of new bone, which is especially seen in the skull, starts 
from the periosteum and from the marrow, causing thickenings of the 
bone. 

Osteomalacia. — Osteomalacia (mollities ossium) is a rare dis- 
ease, occurring especially in pregnancy, and is characterized by a rapid 
and general resorption of the inorganic salts, advancing from the 
centre outward and including all except a thin layer next to the peri- 
osteum. The marrow is increased and splenified, or replaced by a dark, 
semifluid material. On section, the spaces contain a reddish, gelatinous 
mass, which later becomes yellow and fatty. Cysts containing a clear, 
turbid, or hemorrhagic fluid have been seen in the interior of the 
bones. The bones are very light, bend and break readily, or may even 
be cut with a knife. Fractures are commonly multiple, occur spon- 
taneously or from very slight injury, and tend to repair, even in the 
active stage of the disease, the callus, however, remaining free from 
bone salts. At first the disease is limited to the pelvis ; later the entire 
skeleton may be involved. In the so-called non-puerperal form the 
disease starts in the spongy bones of the vertebrae and thorax, extend- 
ing to the extremities and finally even to the cranium. The sacrum 
is pushed downward by the weight of the body and the acetabula 
upward and inward by the femora, producing a characteristic pelvic 



BONES AND JOINTS 285 

deformity. The disease is associated with general cachexia and often 
with pneumonia. 

Periostitis. — -The normal periosteum presents a yellowish-gray 
color, while in suppuration it is distinctly yellow. It may be raised or 
inflamed by traumatism, perforation of compound fracture, abscesses, 
tumors, infectious granulomata, or extension of inflammation from 
neighboring structures. Blood under the periosteum, particularly near 
the epiphysis, is seen in children with Barlow's disease. Simple acute 
inflammation, usually local, produces a reddening, a thickening, and a 
greater adherence of the periosteum to the bone. Suppurative perios- 
titis, generally associated with osteomyelitis, affects growing bones, 
and is rare after the union of the epiphyses. The exudate, or the 
hemorrhage beneath the periosteum, rapidly separates the membrane 
from the bone, causing stretching, occlusion, or thrombosis of the 
blood-vessels passing into the bone; hence necrosis of the superficial 
osseous layers results. Pyaemia and infective fat embolism may oc- 
cur before the abscess is opened. A diffuse form, attacking the long 
bones in those presenting a strumous diathesis, often ends in a rapid 
suppuration. 

Fibrinous, ossifying, or productive inflammation follows chronic 
inflammation of the joints, syphilis, rickets, and tuberculosis, and re- 
sults in osteoses, or bony thickenings. The periosteum is hardened, and 
a projecting node is formed beneath it, which may become fibrous or 
calcified (periostitis ossificans). This calcification begins as a vertical 
process at the surface of the bone, at first distinguishable from the old 
tissue, but later blended with it. In syphilis the subperiosteal nodes 
show a marked tendency to suppurate, and in rare cases suppuration 
occurs, but due to other causes, producing a malignant purulent perios- 
titis. Typhoid bacilli have been recovered from these cases. Albu- 
minous periostitis, a mild inflammation with a ropy, albuminous exu- 
date, is found only in the bones of the young. Tuberculous periostitis 
also occurs, most often in young patients, and has more or less sharply 
defined granulomatous foci, containing tubercles which become caseous 
and soften, and give rise to peripheral caries, sacculated cold abscesses, 
consecutive abscesses, sinuses, or fistulous tracts. The caseous nodes 
are surrounded by a zone of induration and granulations, which may 
be so luxuriant that they form mushroom-like excrescences over the 
external orifice of the sinus. Simultaneous with increase of the caries 
there are proliferation of the periosteum and the formation of con- 



2 86 POST-MORTEM EXAMINATIONS 

siderable new bone. This is usually absent in the cranial bones, where 
resorption alone more often occurs. 

Rhachitis. — Rhachitis, or rickets, is a constitutional disease of 
childhood, characterized by alterations in the conversion of cartilage 
into imperfect osseous structure. Congenital rickets is rare, the so- 
called fetal rickets being merely a disturbance of growth closely resem- 
bling myxcedema. Rhachitic changes affect both the periosteal and 
medullary aspects of the long bones, especially between the shaft and the 
epiphysis, where a soft and irregular zone of proliferation, five or ten 
millimetres thick, is found. The bony tissue is softer and more vascu- 
lar than normal ; the marrow, wider and darker in color. The perios- 
teum strips off easily, revealing a spongy tissue which looks like decal- 
cified bone. Large osteoid formations occur under the periosteum at 
the insertions of the tendons and aponeuroses. The shafts of the long 
bones are usually bent and shortened and the short bones flattened. 
The cranial bones are thin and atrophied at the sites of pressure 
(craniotabes) ; the frontal and parietal bones often have flattened 
swellings, and the fontanelles remain so large that the head suggests 
hydrocephalus. A swelling may occur around the hip, simulating 
coxalgia. Associated with the bone lesions are anaemia, enlarged 
spleen, changes in the liver, muscular atrophy, and catarrhal inflamma- 
tion of the mucous membranes, especially of the intestines and respira- 
tory tract. The lungs and heart often present changes due to the 
deformity of the chest. Dentition is delayed. After the active stage 
of the disease the bones become very hard, heavy, and deformed. 

Tendons, Sheaths, and Bursje. — Acute tenosynovitis, simple or 
hsematogenous, results from wounds, bruises, strains, or excessive exer- 
cise. Gonococci, Pneumococci, or pus cocci infect the tendons usually 
of the dorsum of the hand, producing a purulent exudate, which shows 
a marked tendency to burrow between the sheath and the tendon, 
sometimes for considerable distances. In the dry form deposits of 
fibrin are found upon the inner surfaces of the sheath, giving rise to a 
rubbing or creaking sensation. The tendon is cloudy and swollen, the 
intervascular substance often suppurating or necrotic. Chronic teno- 
synovitis is generally gouty or rheumatic or the result of healing 
wounds. Calcareous deposits or gouty urates are particularly common 
in this form, and may cause necrosis, inflammation, or the formation 
of new fibrous tissue. Tuberculous tenosynovitis occurs in the walls 
of the sheath, with exudation. In advanced stages there may be 



BONES AND JOINTS 287 

fungous granulations on the tendon. The tubercle bacillus may be 
found in arborescent lipoma, a papillomatous, fatty outgrowth of the 
synovial lining, it being a debated question as to whether or not this 
organism causes the lesion. Hygroma or ganglion, due to chronic 
irritation, is a cystic mass which contains rice-like bodies in a serous 
fluid beneath the sheath of the tendon. 

Acute bursitis, acute hygroma, is a fluctuating tumor with serous, 
serofibrinous, or purulent exudate, the result of injury or hemato- 
genous infection. The walls are generally thin, but may be greatly 
thickened. In the chronic form, hygroma, hydrops bursarum, or house- 
maid's knee, the contents, in the early stages, are mucilaginous and 
viscid; later, thin and limpid. Loose bodies are frequently found in 
these cysts. Tubercles may develop in the walls of the sac, associated 
with serous effusion, or the walls may become thickened and per- 
meated by fungous granulomatous masses which may undergo caseous 
degeneration. A ganglion is a round, oval, or lobulate cyst, varying 
in size from that of a pea to a pigeon's egg, and containing a reddish- 
yellow, crystalline jelly or colloid material, probably the result of a 
recurring slight injury. It appears on the dorsal aspect of the inter- 
carpal joints. 

Tumors, Cysts, Parasites, etc. — True osseous tumors occur, 
which may be primary or secondary, myelogenic or periosteal. Oste- 
oma, exostosis, osteophytes, and enostosis are found, the latter arising 
from the periosteum or cartilage, during the period of growth at the di- 
aphyses of the long bones. Two kinds of osteoma are seen, — the can- 
cellous, or spongy, and the compact osteoma. On the skull they are 
usually small, round, conical, or mushroom-shaped. Chondromata 
usually arise from congenital, malplaced islands of cartilaginous tissue, 
though often not until late in life, and are found especially in the 
hands and feet of children and young adults, sometimes producing 
marked and grotesque deformities. They are nodose or tuberous ex- 
crescences which, especially on the scapulae, long bones, or ribs, reach 
considerable size. They may soften and form bone cysts. The mye- 
logenous are at first covered with a shell of bone. Cartilaginous 
exostoses start from the epiphysis, as long or rounded bony projec- 
tions, the apex or a greater part of their surface being covered with 
cartilage. These new growths undergo fatty, calcareous, and mucoid 
degeneration. Lipofnata and angiomata are rare. Fibromata, nodular 
and highly vascular growths, occur on the facial and cranial bones and 



2 88 POST-MORTEM EXAMINATIONS 

in the buccal and nasal cavities. A more rare tumor is the encapsulated 
myxoma, which arises simultaneously in the periosteum and marrow, 
the myelogenous form having no capsule and destroying the bone 
rapidly. Both varieties give rise to cysts, single or multiple. The 
sarcoma is the most common primary tumor, and the cells comprising 
it may be round, spindle-shaped, or giant-celled. It is often telangiec- 
tatic. The myelogenous sarcoma, usually occurring in the epiphysis 
of the tibia, humerus, etc., is, even until it reaches considerable size, 
covered with a bony shell, which may fracture spontaneously. On 
section, a milky fluid may exude. Periosteal sarcomata occur any- 
where and are generally mixed tumors. A special variety, chloroma, 
green and yellow in color, is seen in the facial and cranial bones. Car- 
cinoma is always secondary and is usually due to direct extension; it 
is seen in the skull, sternum, and ribs, where it forms either a circum- 
scribed node or diffuse infiltration and is always accompanied by 
lacunar resorption. 

Cysts arise from lacunar atrophy, osteomalacia, disintegration, or 
excessive resorption. They are common on the alveolar processes of 
the upper or lower jaw, associated with enlarged and tortuous veins, 
and on the clavicle, usually connected with some solid tumor. A turbid 
or hemorrhagic fluid exudes on section. 1 

The Echinococcus is the most common parasite. It occurs in the 
long, pelvic, cranial, and vertebral bones as a single sac or as internal 
or external daughter cysts. There are always associated some resorp- 
tion and atrophy of the affected bone, and there may be distention, 
inflation, or spontaneous fracture. Cysticercus is very rare. 

Aneurisms are generally anastomotic, but primary aneurism may 
occur, usually in the cancellated tissue of the head of the tibia, asso- 
ciated with absorption of the compact bone and periosteum. Hcema- 
tomata are occasionally produced by hemorrhage following trauma or 
rupture of a softening tumor. 

1 For a description of the benign dentigerous cysts of bones see Bloodgood, Jr. 
Amer. Med. Assoc, Oct. 15, 1904; of pelvic deformities, Breus and Kolisko, Path. 
Beckenformen, 1904; and of "poker back" (spondylosis), Fortschr. a. d. Gebiete 
der X-Strahlen, 1904, vol. vii. 



CHAPTER XVIII 

POST-MORTEM EXAMINATIONS OF THE NEW-BORN 1 

The post-mortem examination of a child may be performed in 
a similar manner to that of an adult. The thoracic and abdominal 
organs of a babe when exposed to view are well shown in Fig. 
164. That several hundred years ago the dissection of the fetal 
structures was well understood, is seen by reference to Fig. 165. 

In performing a postmortem on a child it is sometimes advanta- 
geous to remove the viscera en masse, scissors being largely used for 
this purpose in place of the knife, even to the cutting of the clavicles 
in their central part. In France evisceration is done quite frequently 
in the adult, and has the advantage of saving time by permitting the 
removal of the spinal cord while the thoracic and abdominal organs 
are being examined both from behind and in front. To practise evis- 
ceration the trachea and oesophagus are twice tied as high up as prac- 
ticable, divided between the ligatures, and the lower portion then ele- 
vated with the free hand. All the posterior attachments are cut as 
close as possible to the vertebral column until the diaphragm is reached. 
The cervical and thoracic organs are then brought out of the body 
and laid over the costal margin opposite the side upon which the 
operator next works. The diaphragm is now excised laterally and 
posteriorly, adhesions being severed with the knife as before. It is 
well to pull from below upon the liver, stomach, and spleen, so that 
these organs will not be injured by the manipulations. The crura 
being cut loose, the diaphragm is free. The posterior peritoneum 
having been already incised by the removal of the diaphragm, the kid- 
neys are readily found from above, and when removed the psoas 
muscles come prominently into view. The common iliac vessels, round 
ligaments, etc., are next incised. Two ligatures are now applied to 
the rectum, which is then divided between them. When everything 
which holds the abdominal organs in place has been loosened with the 
hand, the organs of both the thorax and the abdomen can be readily 
removed, leaving only the bladder and organs of generation in situ; 

1 For weights and measurements, see Chapter XXIV. 

19 289 



290 



POST-MORTEM EXAMINATIONS 



these may be excised later, in the same manner as that described for 
the adult on page 17; or, by means of the incisions there given, re- 
moved while still attached to the other abdominal viscera. The cervico- 
thoracic abdominal cavity is then to be carefully inspected. 

The body of a child thus disembowelled can be kept for a long 
time, especially if the thoracic and abdominal cavities are packed with 
a mixture of equal parts of bran and salt to which a little white arsenic 
has been added. The cadaver may then advantageously be surrounded 
with cotton and a circular bandage applied to the chest and thorax. 
Parental consent to the performance of an autopsy may sometimes be 
obtained by thus giving assurance of the preservation of the body. 




Fig. 166. — Actual and relative size of, a, the kidney; b, small intestine; c, spleen ; d, large intestine; and 
e, appendix, in a full-term child, The manner in which the appendix comes off is also well seen. 



In the babe there will at once be noticed the large size of the ap- 
pendix, and the manner in which it forms its connection with the caput 
coli. Fig. 166 shows the relative size of the appendix in its relation 
to the kidney and spleen. The liver and the adrenals appear abnor- 
mally large in proportion to the other organs. The perpendicular situa- 
tion of the stomach is to be noted, it being more difficult to distinguish 
the greater and lesser curvatures than in the adult. The dissection of 
the cardiac plexus should always be made after diphtheria and other 
contagious diseases attended with cardiac failure. This examination 
also includes the pneumogastrics and the cervical sympathetics. Wris- 
berg's ganglion (Fig. 74) is found by looking carefully in the region 
of the arch of the aorta, the right branch of the pulmonary artery, 
and the ductus Botalli. (Fig. 167.) Walckhoff believes that the 



Umbilical vein 
Umbilicus 




Left hypogastric 

artery 



Fig. 164. — Post-mortem examination of new born babe. 



•**&& rtjf* <€ 




'J •^s* 


•Si 




< ' . . ' . , 


1 M 



L 



Right pulmonary artery 




Left pulmonary artery 



Pulmonary valves 



Papillary muscle and tricuspid valve 



Fig. 167.— Examination of the ductus arteriosus. The sound is represented as introduced into the 
ductus arteriosus Botalli ; this duct usually closes about the fourth day after birth. Congenital aneu- 
tisms sometimes occur here, and one of the theories of the formation of aneurisms of the aorta is based 
upon weakness at this spot. (After Nauwerck. ) 




Fig. 168. — Examination of the umbilical vessels. (After Nauwerck. 




Fig. 169. — Removal of the spinal cord of a child. 



POST-MORTEM EXAMINATIONS OF THE NEW-BORN 



>9I 



expansion of the lungs changes the position of the heart to such an 
extent that the arterial canal is at once twisted, thus stopping the circu- 
lation through it. The unexpanded lungs are of firm consistence, do 
not crepitate, and do not cover the anterior surface of the heart. The 
color is a brownish slate. The expanded lungs are of light rose tint, 
somewhat blood-stained, except where the bluish spots of fetal atelec- 
tasis persist. The methods of examining the umbilical vessels are 
readily seen by referring to Figs. 164, 165, and 168. Study with 
care the point of insertion of the gelatin of Wharton to the circular fold 
of the skin at the umbilicus in a new-born babe. The fontanelles and 
the cranial sutures should be most carefully studied, as the mechanism 
which admits of such compression during labor is most wonderful. 

The removal of the child's brain is more difficult than that of an 
adult, because, first, it is much softer, and, second, the dura is normally 
adherent to the cranium. But it is easier in one respect, — the bones 
and sutures are not ossified. In a new-born child the brain is so soft 
that its removal without injury is almost impossible. In such cases 
it is advisable to lay the body for a short time on ice sprinkled with 
salt, in order that the brain may become firmer by the consequent low- 
ering of the temperature. By another method — and it is the one from 
which I have obtained the best results — the child is placed in a large 
basin or tub containing a strong solution of common salt (about half 
a bucketful to four or five times this amount of water) and held steady 
by an assistant while the brain is removed by operating beneath the 
surface of the liquid. As brine of the above strength has a specific 
gravity slightly greater than that of the cerebral substance, it affords 
a more general and even support in the subsequent manipulation, thus 
lessening the liability of damage in the removal of the brain. 

The method in detail is as follows : The scalp is incised across the 
vertex and the flaps are turned forward and backward as in the adult. 
With scissors having well-rounded points the sutures and dura are 
cut through well down to the base of the skull. The five flaps thus 
formed are pulled outward and, if necessary, cut partly across their 
base with strong scissors. While the brain is being removed the body 
should preferably be held in the salt solution. Begin by removing the 
falx cerebri and longitudinal sinus, then the frontal lobes, olfactory 
bulbs, etc., in the usual order. When the tentorium and falx are cut 
through, the brain can be pushed out into the solution, where it will 
float. If it be desired to harden the brain, it is well to place a jar of 



292 



POST-MORTEM EXAMINATIONS 



Muller's or other hardening fluid in the brine and under the brain as 
it floats therein, care being taken in the transfer to allow as little as 
possible of the salt solution to enter the jar, though the fluid should 
immediately afterwards be changed for a fresh supply. 

From the body of a baby the spinal cord may be removed with 
scissors alone, as the parts are easily cut through. The lines for the 
incisions through the skin and the vertebrse are made in the same 
manner as in the adult, but neither knife nor saw is required, the scissors 
being strong enough to penetrate easily the soft bony structures of the 
vertebral column in a child under fifteen months of age. (Fig. 169.) 
In babes the spinal cord is relatively much firmer than the brain. 

In autopsies on babes suspected of being the victims of hereditary 
syphilis it is often important to look for the fatty changes produced 
by that disease at the junction of the cartilage and the bone in the 
femur. For this purpose a longitudinal incision is made directly over 
the head of the os femoris and the soft parts are dissected until the bone 
is reached. The ligaments are then incised and the head is disarticu- 
lated. The shaft is held by the left hand securely wrapped in a towel 
while a perpendicular incision through the cartilaginous head is made 
down to the bone; should this be much ossified, the incision may be 
continued with a saw. After sawing for about two inches, a knife is 
introduced and one segment is broken off. The presence of a yellowish 
area of fatty degeneration, more conspicuous in the osseous portion 
than in the cartilage, shows an interference in the nutrition of the part, 
quite characteristic of hereditary syphilis. (Figs. 170 and 171.) 

The centre of ossification of the lower epiphysis of the femur is pres- 
ent at the end of the ninth lunar month of intra-uterine life. In over 
seven hundred full-term infants examined by Vibert and Liman it was 
found to be absent in only sixteen cases. To determine the presence 
or absence of Beclard's sign (presence of the centre of ossification in 
the femur) the knee is forcibly flexed, and a transverse incision made 
below the patella, thus exposing the knee-joint. The lower end of 
the femur (epiphyseal cartilage) is then cut in thin sections perpen- 
dicular to the axis of the bone until the greatest diameter of the 
femoral osseous centre is found, which in a child at term will 
measure from a half to five millimetres across, its red color afford- 
ing a striking contrast to the gray cartilage." (Fig. 172.) This 
area resists putrefactive changes. The ossific centre of the tarsal 
cuboid bone is still more reliable in determining maturity, as this 



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POST-MORTEM EXAMINATIONS OF THE NEW-BORN 293 

centre appears at the last month of fetal life. Another sign 
of importance in a full-term child is the presence of eight separate 
small dental compartments in the inferior maxillary bone, four on 
each side of the median line, and a large space towards the ramus 
which has not yet had the partitions divided off, though an attempt 
at their formation may often be seen. To determine if the child be 
viable the osseous centre of the os calcis should be examined, as this is 
first found between the one hundred and ninety-sixth and the two 
hundred and tenth day of fetal life. 

After a careful study of the urine of the new-born, Sabrazes x 
concludes that the secretion of the fetal kidneys possesses hemolytic 
properties and is poor in chlorids and phosphates. Some authorities 
find no phosphates until after two complete days of extra-uterine 
existence. In the renal tubules are found during the first week of 
life considerable quantities of precipitated sodium urates, causing in 
the pyramids yellowish-white lines which converge towards the apex 
of the papillae. These are supposed to prove that the infant was born 
alive. If a child was born before term, meconium is found in the 
small intestine alone, but if born at term, it is found in the large intes- 
tine. The kidneys are lobular, as in ruminants. 

The latest investigations lead to the conclusion that puerperal 
eclampsia, in which there is laking of the blood-corpuscles and a ten- 
dency to the formation of thrombi and emboli, arises from a defective 
excretory power of the mother, usually referable to the kidneys, but 
that the actual toxin is a fetal product, the added stress of which 
upon the defective eliminating powers of the mother precipitates the 
eclamptic attack. A placental theory for the etiology of eclampsia has 
also been advanced. The liver of the mother shows congestion and 
infarction, and degenerations predominate. Raubitschek 2 believes 
that the secretion (Hexenmilch) frequently found in the mammary 
glands of the new-born is the result of a necrosis and the separation of 
epithelial cells in the acini and ducts of these glands, which are thus 
shown to be at this stage analogous to the sebaceous glands. The 
secretion of colostrum immediately preceding lactation in the puer- 
perium is of similar origin. 

The greenish color of the large intestine of a new-born babe is 
due to meconium, which is composed of cholesterin, crystals of sulphate 

1 Hebd. des sciences med., October 5, 1902. 

2 Z. f. Heilkunde, vol. xxv, no. 1, p. 16; abs., Amer. Med., March 26, 1904. 



294 POST-MORTEM EXAMINATIONS 

of lime, shed epithelium, biliverdin corpuscles, and a highly refractive 
granular debris. 

Blummer 1 considers the status lymphaticus to be a definite patho- 
logic entity, probably associated with, if not due to, a condition of 
intermittent lymphotoxaemia, and at times capable of playing an im- 
portant role in sudden death, fatal anaesthesia, and infection. In some 
cases sudden death is undoubtedly mechanical and due to asphyxia 
caused by the enlarged thymus pressing on the trachea. 

The following two examples of the many which have come under 
my personal observation show the necessity of constant vigilance on 
the part of the practising physician in order that he may draw correct 
conclusions from the pathologic data presented to his view. Two 
days after its birth a babe came upon the post-mortem table of one 
of the hospitals with which I was connected some years ago. The 
autopsy revealed a completely imperforate rectum, the anus likewise 
being imperforate. The physician in charge had ordered immediately 
after birth that a glycerin suppository should be administered morning 
and evening. The nurse reported each time upon the hospital records 
the carrying out of the order! 2 In 1896 there came by train to 
Philadelphia a hard-working colored woman who was about five 
months pregnant. Feeling her labor pains coming on she took a cab 
at the Broad Street Station, and was driven to one of our large hos- 
pitals, where she was duly delivered of a dead child. The cabman 
returned to his post, seeking more work. Upon being again employed 
a five-months' colored foetus was found on the floor of the carriage. 
At the Coroner's inquest the mother swore that she was unaware of 
the fact that she had given birth to the child while in the carriage 
and that no abortion had been performed upon her person. She con- 
sidered the premature labor as being due to hard work. At the hos- 
pital the placenta had not been critically examined, the existence, there- 
fore, of a twin pregnancy not being established at the time of the 
delivery of the dead foetus. 3 



1 Johns Hopkins Bulletin, October, 1903. 

2 Cattell, Annals of Gyncec. and Pediatry, September, 1893, p. 759. 

3 Cattell, Int. Med. Mag., February, 1897, p. 80. 



CHAPTER XIX 

RESTRICTED POST-MORTEM EXAMINATIONS 

In case permission to open the thorax is refused, the diaphragm 
may be severed from its anterior attachments, and the lungs, the heart, 
and even the tongue and adjacent parts may be removed en masse 
through an abdominal incision or a laparotomy wound. 

Should the avoidance of visible mutilation be imperative, it is pos- 
sible to examine and, if necessary, to remove both the abdominal and 
thoracic viscera through the rectum or perineum in males or through 
these parts and the vagina in females. In the male this procedure is 
performed in the following manner : 1 

The body is placed on the back, with the buttocks very near the 
end of the table and the thighs widely separated and flexed upon the 
body. The scrotum is then well drawn up, and an incision is made 
from the perineoscrotal junction to the margin of the anus and down 
to the bulb. The knife is carried around this and through the sub- 
jacent tissue to the pelvic fascia underlying the vesicorectal pouch, 
without injuring the bladder or rectum. The left arm being bared to 
the shoulder, the hand is introduced through the incision, and gradually 
forced up between the parietal peritoneum and the rectus muscles to 
the diaphragm. The peritoneum may be opened, but the intestines will 
invest the hand like a tightly fitting glove and make the manipulation 
more difficult. If unable to perforate the diaphragm with the fingers, 
a scalpel may be carried up, with the blade flat against the index-finger, 
and a nick made in the muscle, the knife being then withdrawn and the 
opening enlarged with the fingers. The lungs may be examined by 
palpation, any adhesions broken up, and the organs dragged into the 
abdominal cavity, the roots being severed with a knife, after which 
they may be removed. The heart can be examined in a similar manner, 
except that, before it can be moved very far, scissors or a knife will be 
necessary to sever the large vessels. The kidneys, adrenals, spleen, 
stomach, etc., may be removed in this manner, but the liver must gen- 
erally be divided into its lobes in order to get it through the incision. 
The organs are examined in the usual manner and returned to the 
body; some wads of oakum may then be pushed into the abdominal 
cavity and the perineal incision very carefully closed by hidden sutures. 

1 H. A. Kelly, Medical News, June 30, 1883. 

295 



296 POST-MORTEM EXAMINATIONS 

It is also possible to make the examination through the rectum, but the 
sphincter is left dilated and gaping, presenting a much more con- 
spicuous and unsightly appearance than the perineal incision. 



This method is most difficult of accomplishment when the operator's 
arm measures more than ten or eleven inches around the biceps, espe- 
cially in subjects of only average size. The work is very arduous, 
because of the strained and cramped position which the hand and arm 
must assume in order to pass the promontory of the sacrum. Coplin 
suggests the use of the photographer's thimble in tearing the tissues 
within the abdominal cavity. 

Access to the interior of the trunk may readily be had from the 
dorsum by making a longitudinal incision to one side of the spinal 
column and sawing the ribs close to their vertebral attachments. When 
the examination is made through the vagina, an oval incision such 
as is described on page 194 may be made, or a vaginal hysterectomy 
may first be performed (Figs. 106 to 114, inclusive). 

The brain may be removed almost intact (in two or three pieces) 
by making a transverse four-inch incision across the fifth cervical ver- 
tebra, dissecting up the soft tissues, and cutting a V-shaped segment 
out of the occipital bone by introducing a saw through the foramen 
magnum and sawing towards the ears and then across transversely. 
(Fig. 152, E A F.) A rapid, but not scientific, method of diagnosing 
hemorrhage, which also permits of the removal of the brain in small 
pieces, is referred to on p. 204. 

An examination of the bones of the face is sometimes desirable, but 
the circumstances and conditions under which it may be required are 
so variable that the method must be left entirely to the judgment of 
the operator. Disfigurement is so readily noticed that nothing further 
than a superficial examination should be attempted without the per- 
mission of those interested. The simplest and most unobjectionable 
method of procedure is to introduce the knife through an incision pre- 
viously made from the ear to the neck and dissect subcutaneously the 
tissue investing the bony structures. If the bones of the face are to 
be removed, it may be necessary to make a transverse incision, the point 
of election being the furrow between the inferior maxilla and the neck. 

If the oral cavity must be examined through the orifice of the mouth 
after rigor mortis has set in, the rigidity may be overcome by placing 
towels soaked with hot water over the muscles of the jaw. Such appli- 



RESTRICTED POST-MORTEM EXAMINATIONS 



297 






cations repeated for about five minutes usually suffice. Do not use a 
chisel to pry the jaws apart, as is sometimes recommended, because of 
the danger of breaking the teeth or knocking them out. As the rigidity 
rarely returns, it is advisable at the end of the examination to close the 
mouth with a few sutures through the mucous membrane of the upper 
and lower lips. 

The nasal cavity may be exposed and examined by detaching with 
a knife the upper lip from the maxilla from within and then removing 
with a saw such portions of the superior jaw-bone as will afford room 
for inspection of the parts under consideration (Figs. 173 and 174). 
By the removal of the eye the pituitary body, Gasserian ganglion, etc., 
are rendered easily accessible. Indeed, it is surprising what extensive 
dissections may be made in the region of the face and neck in the ways 
just mentioned, thus affording an opportunity for thorough digital 
examination of areas not open to ocular inspection. 



CHAPTER XX 

RESTORATION AND PRESERVATION OF THE BODY 

When the examination has been completed, the cavities of the body 
should be thoroughly sponged out, all blood and other fluids removed, 
and bleeding vessels tied to prevent leakage. The organs should then, 
as nearly as possible, be returned to their respective positions, and the 
cavities filled with dry bran, absorbent cotton, sawdust, sea-weed, or 
shavings, in sufficient quantity to restore the original contour of the 
body, covering the abdominal contents with old cloth or papers to pro- 
tect the under surface of the seam. The brain is generally put into the 
abdominal or thoracic cavity, owing to the great difficulty in returning 
it to the skull. If several postmortems be made at the same time and 
place, care should be taken to return the organs to the proper body, nor 
should a cadaver be used as a convenient receptacle for the disposal of 
specimens which are no longer of any use. In the case of a child a 
small bag may be packed with sand or sawdust so as to assume the 
shape of the brain and placed inside the calvarium; the brain itself, 
after dissection, is placed in the abdominal or thoracic cavity. It is 
unwise, however, to permit any member of the family to witness this 
procedure. 

In all private cases it is important to secure the skullcap in position, 
to prevent the unsightly disfigurement produced when it slips after the 
scalp has been sutured. A number of efficient methods have been 
devised, but the one selected usually depends upon circumstances or 
upon ingenuity. The fossae of the skull as well as the calvarium may be 
filled with plaster of Paris, and while the plaster is still soft a short, 
stout stick of wood is pushed through into the foramen magnum, the 
upper end extending to the skullcap, which is then adjusted. When the 
plaster hardens, the calvarium is well fastened in good position. If in 
removing the skullcap the precaution is taken to crack at least a part 
of the inner table with the chisel and hammer, projecting pieces of bone 
are usually left, which interlock and hold the calvaria snugly in position 
when it is replaced. 1 If the edges of the temporalis have not been too 
badly lacerated, sutures may be passed through the muscle and fascia 

1 Mallory and Wright, Pathological Technique. 
298 







Fig. 173. — Method of examining nasal cavities, antrum of Highmore, etc. By means 
of a knife the uppermost mucous membrane between the lip and the superior maxilla is 
incised, the upper lip being elevated with the left hand during the incision. Vertical 
sawing is now done in the median line, and the tooth extracted at the point where the 
lateral sawing is to take place. The bone-forceps readily bring the desired portion of 
bone away, or it can be loosened by means of a chisel. 




Fig. 174.— Appearance of the part after removal of a portion of the superior maxilla for 
the purpose of examining the nasal cavities, antrum of Highmore, etc. 




Fig. 175.— Method of sewing up the body. 




Fig. 176.— Appearance of body after it has been sewed with base-ball stitch. The sewing has been done 
from above downward, and there is no puckering at the point of starting. 




Fig. 179. — Method of withdrawing blood from a body previous to its injection with an embalming 
fluid. A, trocar inserted into left auricle of the heart; B, stop-cock; C, exhaust valve; I), outlet valve 
for air ; E, syringe. The valve D is used when fluid is to be pumped into the body. 




Fig. 180. — Injection of body with embalming fluid. A, cannula inserted into brachial artery; B, tube 
going down to bottom of bottle containing embalming fluid ; C, hand-bulb and valve, by the use of which 
the fluid is forced through the arterial circulation. 







Fig. i 8 i. —Refrigerating room. A, recording thermometer and middle tier of shelving; B and Z>, tiers of shelving; 
C, brine tank ; E, pipes of refrigeration apparatus. 




Fig. 182— Preparation of bodies after removal from refrigerating room. A, bath; B, air-condenser and injecting 
apparatus ; C, pulley suspension apparatus ; £>, exterior of refrigerator box ; B, odorless excavator barrels. 



RESTORATION AND PRESERVATION OF THE BODY 



299 



with very satisfactory results. Small holes may be drilled in the skull 
and sutures passed through them, or a wide staple (or double-pointed 
carpet-tack) may be used for the same purpose. Another method is to 
drive a small wire pin, or a wire nail with its head cut off, about half 
an inch long, half-way into the diploe of the skull and insert the other 
end in a hole, made to correspond, in the calvarium. Two of these pins 
should be enough. Still another method is that described by Slee. 1 The 
posterior line of sawing, instead of stopping at the angle, is continued 
an inch or more into the temporal bone; a piece of ordinary roller 




Fig. 177. — Slee's method of fixing the skullcap. 



bandage is then stretched across the skull and inserted in the saw-cut ; 
the calvarium is replaced, the ends of the bandage are brought together 
over the vault and securely sewed, pinned, or tied (Fig. 177). A ready 
and efficient method of my own for fixing the skullcap is to make in two 
or three places on the thickest portions of the skull vertical pencil-marks 
across the line of sawing and extending an inch above and below it, 
saw these for three-quarters of an inch or so, and into each pair of saw- 
cuts insert the ends of a thin, double-wedge-shaped piece of iron or 
steel so made that it will be tightly pushed into place when the skullcap 

1 Medical News, December 31, 1892, p. 737. 



30o 



POST-MORTEM EXAMINATIONS 



is affixed. Any portion projecting beyond the bone is hammered down. 
For another method see Fig. 178. 

If the vault of the cranium is to be retained by the physician 
and a substitute cannot be found, take a square piece of pasteboard 
about three millimetres thick (thinner for children) and soak it in 
warm water for a quarter of an hour, or until it is soft enough to be 
easily moulded over the skullcap. Having done this, cut the paste- 
board parallel to the edges of the saw-cuts and overriding them from 




Fig. 178.— Author's method of holding skullcap in place. Four holes are drilled in the 
bones on each side, two to the right and left of the angle in the temporal bone and two in 
the skullcap just above the angle. Saw-cuts to hold the wire or string are made in the vertex, 
the string being thrust in and out of the openings and tied at any convenient spot. 



ten to fifteen millimetres. Then fill the skull cavity with wadding 
or plaster of Paris. Remove the pasteboard from the skullcap just 
as soon as it becomes so dry that when it is applied to the base of the 
skull the edges will adapt themselves to the border thereof. With a 
knife the edges of the pasteboard are cut obliquely, any folds which 
are formed therein are incised along their crests, one edge is tucked 
in under the other, and the surface smoothed by the use of the knife. 
Strong twine is bound twice around and the pasteboard thus securely 
fastened to the base of the skull. The temporal muscle is drawn up- 



RESTORATION AND PRESERVATION OF THE BODY 301 

ward and the skinflaps stitched as is next described. (Nauwerck.) 

The skullcap being secured, the scalp is replaced and sutured with 
glover's or base-ball stitches, — i.e., those made by repeatedly passing 
the needle from within outward. By careful use of black or dark 
thread the incision may be so neatly closed as to escape even fairly 
close inspection. It sometimes happens that by stretching the skin 
becomes baggy. Should such be the case, a small portion of the hairy 
scalp parallel to the original incision across the vertex may be re- 
moved previous to the sewing. 

After the organs are returned, the sternum should be supported 
by paper, or, still better, by old linen. Bran and fine sawdust are very 
useful to fill in with, as they absorb the moisture. Oakum makes the 
sewing difficult. If the organs have been removed through the vagina 
or rectum, these outlets should be doubly sewed, some absorbent 
material having first been introduced to prevent leakage. 

A round stick or a piece of gas-pipe may be placed in the spinal 
canal after the removal of the cord, with the upper end pushed through 
the foramen magnum, especially if any of the vertebrae have been 
taken away, and plaster of Paris may be poured in until the cavity 
is well filled. An old cloth or some paper is then placed on top and 
the whole sewed together. The line of the incision may be covered 
with a strip of adhesive plaster. As in Gersuny's method for the cor- 
rection of deformities, paraffin at a temperature of about 55 ° C. may 
be injected into the body in large quantities and before cooling be 
moulded into the proper shape. 

The abdominal incision is closed by sewing from the pubes to 
the sternum, passing the stitches from within outward, about three- 
eighths of an inch from the cut edges and about half an inch apart, 
alternating on the two sides so that each needle-hole on one side 
will be midway between two on the opposite side. The twine should 
be about half a millimetre thick. Both ends of the suture should be 
securely tied. For the closing stitch it is well to cut the thread near 
the needle, withdraw one end, and tie in a surgeon's knot. Roughly 
estimated, the thread required is twice the length of the incision to 
be closed. Carefully crowd in any extruding fascia and avoid pucker- 
ing of the part. (Figs. 175 and 176.) 

If the mouth has been opened, or any of the tongue removed with 
the structures of the neck, the lips may be held together by a few 
sutures passed through the oral mucous membrane. 



3 o2 POST-MORTEM EXAMINATIONS 

If any portions of bone have been excised, their place may be sup- 
plied by using a properly shaped piece of wood, which is held in 
position with sutures, wire, or strong cord, or by plaster of Paris. 

Finally, the body should be very carefully cleaned and returned to 
the place and position in which it was found. Politics as they obtain 
in some places make the Coroner's physician even clean up the mort- 
uary after sewing up the body ! 

The characteristic " post-mortem odor" is very persistent and de- 
fies all kinds of soap. It usually results from handling the intestines, 
and can best be removed by washing the hands with aromatic spirit 
of ammonia or, in the absence of that, by rubbing them with dry 
mustard and then washing with soap and water, or, still better, with 
some of the newer liquid antiseptic soaps. Ammonia or the aromatic 
spirit thereof will remove iodin stains, while carbol-fuchsin and other 
anilin stains yield to a weak solution of sodium hypobromite. 

Embalmed and Frozen Bodies. — Embalming may interfere with 
the work of the pathologist, the bacteriologist, and the toxicologist. 
Fortunately, the old zinc, mercurial, and arsenical combinations have 
been very largely superseded by formalin, a much more desirable 
preparation, although it may irritate the eyes, deaden the sensibility 
of the finger tips, and even produce an eczema of the hands of the 
obducent. Arterial embalming is at present more used by undertakers 
than any other method of preserving the body after death. It is 
customary among many undertakers first to aspirate the heart and 
remove as much blood as possible (Fig. 179), though this procedure 
is no longer of such importance as formerly, owing to the improvement 
in the preservative powers of the embalming fluids now in use. Re- 
moval of the contents of stomach and intestines is also sometimes 
practised and materially aids the preservation. One of the super- 
ficial arteries is then opened, as the femoral, carotid, radial, or 
brachial, and at least two quarts of fluid slowly injected into the 
vessel. (Fig. 180.) 

Next in importance is cavity embalming or injection of preserving 
fluid into the three body cavities. In the abdomen, the instrument is 
thrust, preferably, through the umbilicus, so that the wound of en- 
trance will not be conspicuous, and efforts are then made to puncture 
the heart, lungs, intestines, liver, and other abdominal organs. The 
gas escapes, any blood exuding is withdrawn, and the fluid is after- 
wards injected, the stream being directed towards the liver. Some 



RESTORATION AND PRESERVATION OF THE BODY 303 

embalmers urge avoidance of any injury to enclosed viscera, and 
remove the contents per rectum. 

The disadvantages of this method are: first, in cases of abortion 
with peritonitis there may be considerable difficulty in determining 
whether the openings were made before or after death; secondly, 
such punctures may also complicate matters by opening up abscess- 
cavities, cysts, aneurisms, etc. ; and thirdly, in cases of poisoning, 
besides allowing the stomach contents to escape, the fluid may contain 
the same substance as that which caused death. Even when formalin 
has been employed, as in the recent Haines case in New Jersey, 
the syringe may have been previously used for injecting an arsenical 
preparation. 

The thorax is best filled by injecting the fluid through a long 
curved trocar passed down through an opening in the trachea. The 
fluid should first fill both lungs, and afterwards the trocar should be 
pushed down so that the point pierces the pleura, and these cavities are 
then to be filled with fluid. The brain cavity is best filled by passing a 
needle up the nose, breaking the cribriform plate, and then injecting 
the cerebrospinal cavities and the sinuses. Any excess of fluid passes 
through the jugular vein to thoracic organs. These methods, though 
preserving the nervous tissue, are not as efficient as the arterial em- 
balming for the preservation of the body and are apt to discolor or 
cause swelling around the face. The trocar may be passed through 
the inner canthus of the eyes by the sphenoidal fissure, or through 
the foramen magnum, thence injecting the brain and cephalic cavity. 
Fluid may also be previously introduced by lumbar puncture. 1 

Nauwerck employs : an injection-syringe having a capacity of 
five hundred cubic centimetres; long cannulas of different calibers, 
with pear-shaped ends and with stopcocks or, preferably, with double 
stopcocks; strong twine; scalpels, scissors, forceps, grooved director, 
hsemostats, an aneurism-needle, and ordinary needles; basins and 
buckets; several packages of absorbent cotton; cloths and sponges; 
and ten litres of a one per cent, aqueous solution of corrosive subli- 
mate, which may be kept in one-litre bottles. His method of em- 
balming is begun by exposing the lower part of the abdominal aorta 
and the two iliac arteries. Two ligatures are placed beneath the 
aorta, about two finger-breadths apart, and the aorta is obliquely 

1 Onuf, Med. Record, July 9, 1904. 



304 



POST-MORTEM EXAMINATIONS 



incised to allow the entrance of the cannula, which is secured by 
tying the distal ligature over it. The injection into the upper part 
of the body is then begun carefully and slowly, pausing occasionally 
when the counter-pressure becomes too great. About three litres 
are injected, more or less, depending upon the appearance of swell- 
ing of the face, seen first about the eyes and chin. The cannula is 
removed, both proximal and distal ligatures are tied, and the aorta 
is cut through. In like manner a litre of the solution is injected into 
each leg through the common iliac artery. A cannula with a double 
stopcock can be used to inject both the upper and lower parts of the 
body at the same time. The mesentery is ligated, and the intestines, 
from the beginning of the jejunum to the end of the sigmoid flexure, 
are removed, opened, washed out, and put in a one per cent, solution 
of bichlorid of mercury, and later replaced in the abdominal cavity, 
wrapped in sublimated cotton, or, where practicable, disposed of by 
cremation. The stomach, duodenum, and rectum are cleaned out with 
sublimate solution and packed with sublimated cotton. The bladder, 
vagina, external ear, and nose are similarly treated. The abdominal 
cavity is carefully wiped with a cloth wrung out of the bichlorid 
solution and dried, and the abdominal incision is sewed. The sur- 
face of the body, with the exception of the hair, is also wiped with the 
solution and dried. If this method fails, Nauwerck injects the pre- 
serving fluid into the carotid and axillary arteries. 

Hewson 1 recommends the following injection for the preserva- 
tion of human bodies for the dissecting-room : 

& Sodium arsenate 2 kilogrammes. 

Potassium nitrate 1 kilogramme. 

Carbolic acid 150 cubic centimetres. 

Boiling water 7850 cubic centimetres. 

Boil until complete solution, then add 

Glycerin 2000 cubic centimetres. 

Formalin (40 per cent, solution) 100 to 150 cubic centimetres. 

Thymol, as much as will go into solution, a piece the size of the 
end of the thumb being sufficient for a carboy of solution. 

About two and one-half gallons of this fluid are introduced into an 
artery — say the common carotid — by gravity, openings having pre- 
viously been made in the toes or in several of the veins if they be 
distended with blood. After injection the body is thoroughly greased, 

1 Phila. Med. Jr., October 27, 1900 ; Amer. Med., February 27, 1904. 



RESTORATION AND PRESERVATION OF THE BODY 305 

covered with paper, bandaged, and placed in cold storage until wanted 
for dissection. Mall embalms with carbolic acid, wood alcohol, and 
ultramarine blue. 

Frozen bodies should not be thawed hastily by the addition of 
warm objects, but should be allowed to remain in a warm room for 
some twelve hours previous to the post-mortem examination. Figs. 
181 and 182 show the refrigeration room of the Medical Department of 
the University of Pennsylvania, planned by Dr. Holmes. The vaults 
of the University of Wisconsin, designed by Professor Miller, are the 
most recent of their kind, narrow brine tanks extending from the 
floor to the ceiling. At the Paris morgue the bodies are frozen at 
— 12 C. to — 14 C. immediately upon their arrival; at the end of one 
day they are placed in a separate apartment having a temperature of 
— 4 C, so as to facilitate their thawing for a postmortem in fifteen 
to twenty hours. (Letulle.) 

Death Mask. — In the making of a death mask about five pounds 
each of plaster of Paris and of modelling clay are employed. Nearly 
all of the clay is rolled out until it reaches thirty inches in length. 
The head is placed perpendicular to the body upon an old pillow, and 
then the face and any hairy portions which are to be included in the 
mask are thoroughly anointed with olive oil or liquid vaselin. Crum- 
pled towels or pieces of paper are now arranged so that when the 
potter's clay is entwined around the head it will be supported and pre- 
vent the liquid plaster of Paris from escaping. Any openings are now 
filled in with the remainder of the potter's clay, and the interior of 
the potter's clay anointed with olive oil. Two quarts of water are 
placed in a bowl and the plaster of Paris is slowly added, the whole 
being constantly stirred with a large spoon until of a gruel-like con- 
sistency, then more of the plaster of Paris is added until it begins 
to thicken, when it is immediately poured into the hollow cavity to 
secure the mould of the face. If the plaster of Paris is good it will 
set in about twenty minutes ; the potter's clay is removed, and the cast 
can be lifted in a single piece from the face. It is then carefully 
packed in cotton, removed to the laboratory, coated with mastic var- 
nish, and oiled. A plaster-of-Paris cast is now made of the mould in 
a similar manner, or the mould itself may be sent to an Italian worker 
in plaster, usually to be found in a city of any size. 



20 



CHAPTER XXI 

DISEASES DUE TO PARASITES 1 

The number of diseases known to be due to pathogenic vegetable 
and animal parasites is constantly on the increase, the recent study of 
tropical conditions by schools of medicine especially established for this 
purpose and the elucidation of problems arising from the digging 
of the Panama Canal and the governing of the new outlying posses- 
sions of the United States having added much to our knowledge on 
this subject. The morbid lesions which are produced by these agencies 
are varied, though rarely characteristic, and require considerable 
bacteriologic and histologic training for their study and proper inter- 
pretation. If contagious diseases are to be stamped out, less attention 
than at present must be paid by our Boards of Health to politics and 
more consideration be given to those affections contracted from the 
lower animals and distributed by the agency of mosquitoes, flies, fleas, 
ticks, cockroaches, bedbugs, etc. Any form of disinfection which fails 
to rid a room of such creatures must now be considered as ineffec- 
tive. The outbreak of yellow fever in the South during 1905, has 
called attention to the drift of public opinion in wishing to increase in 
severe epidemics, extending over a large area of territory, the power 
of the United States Marine Hospital Service over that of the State 
and local health authorities. 

Actinomycosis is a chronic infectious disease, occurring most fre- 
quently in horned cattle (as " lumpy- jaw" or " wooden tongue"), but 
found also in man. The exciting cause, the Streptothrix actinomyces 
(the ray- fungus, so called from the peculiar radiate grouping of the 
filaments with their bulbous extremities), is found in the pus and the 
newly formed granulation tissue in the form of yellowish opaque 
granules, — called " sulphur balls," — which measure from one-half a 
millimetre to two millimetres in diameter. When these granules are 
crushed and placed under the microscope, they present the appearance 

1 For additional data pertaining to the pathogenic micro-organisms, see Chapter 
XXIII, p. 386, entitled " Bacteriologic Investigations." 
306 



DISEASES DUE TO PARASITES 307 

so beautifully depicted by Lebert in his Atlas ( 1856) . A ready method 
of examining the fungus is to collect a tube of pus expressed or 
curetted from an abscess. Incline the tube and let the fibrin coagulate ; 
pick off the granules with a platinum rod, place them on a slide with a 
drop of picrocarmin solution, and after a minute or two apply a cover- 
glass, and examine microscopically. The fungus assumes under these 
conditions a bright yellow color. 1 The semi-translucent forms are the 
most difficult to recognize. The organism may grow outside of the 
body, and under certain circumstances be inoculated into animals. In- 
fection usually takes place from food, generally through a wound or 
abrasion of the mucous membrane, as through the medium of carious 
teeth. In one case reported, the patient had been long accustomed 
to pick his teeth with a straw. In another instance, a young woman 
had acquired the habit of chewing hay while playing golf ; in the latter 
case the first sign of the disease, which was eventually fatal, was in the 
alveolar process. The characteristic primary lesion is a small nodule 
resembling an anatomic wart. Later there occurs proliferation of 
cells, especially of the polymorphonuclear variety, into the surrounding 
fatty tissue, followed by suppuration. The abscesses are at first mul- 
tiple, spherical, and discrete ; in time they coalesce and give a reticulated 
and honey-combed appearance to the part affected. The destruction 
of tissue is often excessive, and metastases may occur. According to 
Bevan, 2 of Chicago, the internal administration of copper sulphate is 
much more efficacious than that of potassium iodid. 

Lesions, classified according to mode of infection, which may 
possibly be hematogenous : 3 — 

I. Actinomycosis of head and neck, with infection from the 
mouth and pharynx. ( 1 ) The jaw is often affected ; caries and 
necrosis of the maxilla may result. (2) The tongue is frequently 
involved. (3) The brain has been the primary seat of the disease. 

II. Actinomycosis of the thorax, with infection through the 
respiratory tract. The lesions are usually unilateral. (1) Chronic 
bronchitis. (2) Miliary nodules in the lungs, formed by masses 
of fungi surrounded by granulation tissue. These may fuse, sup- 
purate, and finally become cavities. (3) Bronchopneumonia. (4) 



1 Presse medicale, 1903, vol. xxvii, p. 654. 

2 Jr. Amer. Med. Assoc, November 11, 1905. 

3 Chicago Surgical Society, December 5, 1904. 



308 POST-MORTEM EXAMINATIONS 

Heart- emboli, or localized parenchymatous myocarditis. (5) Exten- 
sion to vertebrae, ribs, and sternum, resulting in peripheral caries and 
necrosis. 

III. Actinomycosis of the abdomen, with infection practically 
always through the alimentary canal, though possibly, in rare 
instances, through the female genital organs. (1) The stomach 
has been the seat of multiple abscesses which burrowed along the 
diaphragm. (2) The caecum may be involved in a fibrinous and 
ulcerative inflammation. (3) The ano-rectum, (4) the liver, (5) 
the vermiform appendix, and (6) the ovary have been the primary 
seats of the disease. (7) The spleen may be attacked, but this is 
rare, and always leads to purulent inflammation. 

It is more than probable that the pale form of Madura foot (myce- 
toma) may be due to a species of actinomycosis, the black variety being 
assigned by some to another variety of mould. Various varieties of 
Streptothrix, Cladothrix , and Leptothrix have been described as caus- 
ing diseases of the lungs, throat, vagina, etc. 

Anthrax is an acute, infectious, contagious disease, having for 
its characteristic lesion a pustule, caused by the Bacillus anthracis. 
Sheep and goats are especially predisposed, though the Angora sheep 
is apparently immune. In man the disease is contracted in certain 
occupations, as wool-sorting, tanning, etc., and by the ingestion of the 
flesh or milk of an infected animal. The micro-organism is rod- 
shaped, from two to twenty-five microns in length, non-motile (thus 
distinguished from the similarly shaped but motile Bacillus subtilis), 
often united, and growing with great rapidity. Characteristic cultures 
may be made on gelatin plates at ordinary temperatures. The bacillus 
is easily killed, but the spores are very resistant. For many successive 
years Ziegler was able to produce anthrax in mice by inoculations from 
similarly prepared pieces of dry catgut which contained the spores. 
The bacilli are found in the capillaries of the liver, the kidneys, and 
the lungs, in the blood, and in the pustules. Both active and passive 
immunization will confer artificial immunity. Serum therapy is, how- 
ever, more effective in animals than in man. 

In a case which the writer had the opportunity of studying with the 
late Dr. Thomas G. Morton, the pustule was on the palm of the hand. 
The disease was probably contracted from a bone fertilizer, while the 
woman was working with a trowel in her flower-garden. A specimen 
purchased from the same shop at which she had secured the fertilizer, 



DISEASES DUE TO PARASITES o q 

however, failed to show the presence of the Bacillus anthracis upon 
careful and independent search by Drs. Peckham and Ravenel. 

Two sets of lesions are found, depending upon the method of 
invasion, — whether by the skin or by the mucous membranes : — 

I. External Anthrax. — (a) Malignant pustule. At the site 
of inoculation there appears a papule which rapidly becomes a vesicle ; 
later a brown eschar is formed, surrounded by small vesicles and an 
extensive area of brawny induration. The neighboring lymphatics 
are swollen and hard, (b) Malignant anthrax oedema, an extensive 
oedema affecting the eyelids, the head, the arms, and often the entire 
upper extremity. It may terminate in gangrene, enteritis, peritonitis, 
or endocarditis. 

II. Internal Anthrax. — With this form there is always rapid 
post-mortem decomposition. Very soon after death the upper extremi- 
ties, both anteriorly and posteriorly, become dark purple, the nails are 
blackish blue, and dark chocolate-colored fluids issue from the mouth 
and nose. (A) Thorax. The cellular tissues of the upper part of the 
chest are emphysematous and crackle on pressure. On opening the 
thorax these tissues are often found infiltrated with blood and a gelat- 
inous effusion, (i) The pleurae may contain much serum. (2) 
The lungs are engorged with dark-colored blood. Some portions 
are cedematous; others harder than when normal, and of a darker 
red color. (3) The bronchial glands are swollen, hemorrhagic, 
and friable. (4) The pericardial fluid may be increased to six or 
eight ounces. The cardiac muscle is dark colored, soft, and flabby; 
the heart may be empty, or may contain dark, semi-fluid blood in all 
its cavities. The lining membranes of the heart and the larger blood- 
vessels are stained a color varying from cherry-red to dark chocolate, 
according to the time that has elapsed since death. (5) The serous 
membranes throughout show extravasations of blood ; the blood itself 
being only very slightly coagulated. (B) Abdomen. (i) The 
small intestine and the upper part of the large intestine show 
lesions consisting of dark brownish-red infiltrated spots (phlegmonous 
inflammation) about the size of a dime, with a greenish or grayish 
slough in the centre, which are composed mainly of anthrax bacilli 
situated chiefly in the lumen of the blood-vessels (Strumpell). There 
is oedema of all the layers of the gut-wall; the mesenteric nodes are 
swollen. The peritoneal cavity contains considerable serum, which is 
frequently blood-stained ; or there may be gelatinous oedema. Hemor- 



3io 



POST-MORTEM EXAMINATIONS 



rhages appear in the serous membrane. (2) The liver shows less 
change than any other organ ; it may even seem normal to the eye, but 
microscopically the cells will usually show some form of degeneration. 
(3) The spleen may be enlarged, swollen, and soft, or normal in 
size and appearance. (4) The parenchyma of the kidney is gorged 
with dark blood, and hemorrhages appear in the capsule. (C) Ex- 
travasations of blood are discovered between the meninges of the 
brain and spinal cord, and sometimes small infarcts are found. The 
capillaries are engorged. (D) Retropharyngeal abscesses may be of 
this origin. 

Beriberi (Kakke) is an infectious epidemic disease of tropical 
and subtropical countries, characterized clinically by muscular pains 
and weakness, disseminated neuritis, cardiac failure, and anasarca, 
which generally affects the upper extremities, and anatomically by an 
inflammation of the pyloric end of the stomach, and the duodenum. 
Little regarding its origin is definitely known. Various micro-organ- 
isms have been suggested, Wright considering the organism to belong 
to the diphtheria group. Overcrowding, a fish diet, and the drinking 
of arsenical waters seem to predispose to the disease. The stools 
should be disinfected. Two extreme types of the disease are recog- 
nized : — I. The (Edematous form. II. The paralytic or dry form. 

Lesions. — (A) The axis cylinders and medullary sheaths of the 
peripheral nerves appear to be the seat of a special lesion, which is 
essentially a parenchymatous neuritis. The nerves are usually swollen 
and hemorrhagic, but at times appear normal. (B) Atrophy may 
appear in the striated muscles, in which case they are dry and 
shining; or the affected muscles, including the heart, are pale, flabby, 
and fatty. Dangerfield's Beri-beri (1905) is the most important recent 
work on this subject. 

Cerebrospinal Meningitis — Epidemic form (Spotted Fever) 
is an acute infectious disease characterized by an exudative inflam- 
mation of the pia mater of the brain and spinal cord. The Diplo- 
coccus intracellular is meningitidis of Weichselbaum {Meningococ- 
cus) has been demonstrated in most cases to hold a causative relation 
to the disease, being possibly introduced into the system by the 
bedbug, though the nasal route would seem equally probable. During 
an epidemic, domestic animals, as the goat, should be watched 
for signs of the disease. The organism may be found in the fluid 
removed by lumbar puncture, by which method the disease may usually 









DISEASES DUE TO PARASITES 3II 

be distinguished from the tuberculous variety of meningitis, though 
along with other observers I have found the two conditions associated 
together. In two fatal cases examined by me there was a history of 
a fall, though no signs of traumatism were to be found at the autopsy. 

Lesions. — {A) In cases where death occurs early, as it sometimes 
does within twenty-four hours, the meninges of the central nervous 
system may show to the naked eye no change save a moderate serous 
infiltration. In more protracted cases there is a suppurative inflamma- 
tion, chiefly in the pia mater, with varying amounts of serum, fibrin, and 
pus. The cerebral cortex may be compressed and the convolutions 
flattened by an accumulation of exudate over the convexity of the 
brain, in the ventricles, or at the base, the last condition being the 
most common. In the membranes of the cord, also, the exudate is 
greatest in amount posteriorly. Minute hemorrhages may be present 
in the meninges and in the nerve substance of the brain and cord. 
The cranial nerves, especially the second, fifth, seventh, and eighth, 
and the roots of the spinal nerves, are often involved in the inflam- 
matory process. (B) Pneumonia is a frequent complication. (C) 
The nose and throat may be inflamed, and purulent inflammation 
of the labyrinth of the ear may cause deafness. (D) The optic 
papilla may be inflamed or atrophied. (E) The skin and mucous 
membranes may show petechias. (F) The voluntary muscles are 
apt to undergo hyaline and granular degeneration. (G) The joints 
may be the seat of abscesses. (H ) The parenchymatous organs 
show cloudy swelling, which may go« on to fatty degeneration. 

Chickenpox. — See Varicella. 

Cholera Asiatica is an acute infectious disease originating in 
Eastern countries, and is characterized by a profound inflammation of 
the bowel due to the presence of the exciting cause, a spirochseta, the 
Comma bacillus of Koch, which is a motile, screw-shaped micro- 
organism, about half the length of a tubercle bacillus, but thicker. 
(Plate V, no. 5.) It grows readily on artificial media. The bacilli 
are found in large numbers in the rice-water stools, but rarely in the 
vomit. The body is thin and shrunken; muscular twitchings are 
common immediately after death, and the temperature may be elevated. 
Rigor mortis sets in early and is marked; the extremities are flexed, 
the fists closed, and the abdomen scaphoid. There is cyanosis of 
the skin. 



312 



POST-MORTEM EXAMINATIONS 



Lesions. — I. The abdominal organs are dry and the peritoneum 
is sticky. (A) The stomach may be distended with gas, and super- 
ficial hemorrhages may be found in the mucosa. (B) Lesions of the 
intestines are not characteristic of very acute cases, but the bowel 
contains large quantities of " rice-water." In more protracted cases the 
intestine presents a mapped appearance, some areas being hypersemic 
and some anaemic, while other places are hypertrophic and ulcerated. 
The inflammation is well marked in the Peyer's patches. The serous 
membrane is of a rosy-red color and the blood-vessels are prominent. 
The large bowel is contracted and empty. An excellent illustration of 
this condition, taken in 1892 during the cholera epidemic at Hamburg, 
is to be found in Kast and Rumpel's Pathologisch-anatomische 
Tafeln. Cholera again visited this port in 1905. (C) The mesen- 
teric glands are swollen, soft, and of a reddish color. (D) The 
liver shows cloudy swelling, with minute areas of necrosis. (E) 
The spleen is usually normal, but may be softened. (F) The kid- 
neys are swollen, of a violet hue, and show the changes of acute 
diffuse nephritis. (G) The cceliac ganglion is hypersemic, or 
even hemorrhagic (Rokitansky). (H) The uterine mucosa in 
adult women usually shows hemorrhagic infarcts. II. Thoracic 
Organs. (A) The heart is flabby; its left side empty as a rule ; its 
right usually distended with tarry blood. (B) The lungs are 
collapsed and show marked congestion at their bases. Pneumonia and 
pleurisy may be present, and abscesses are not uncommon. There is a 
decided tendency to the formation of diphtheritic exudate on mucous 
membranes, particularly in the throat, colon, and genitalia. Suppura- 
tive parotitis may occur. 

Croupous Pneumonia. — See Pneumonia. 

Dengue is an acute infectious disease, prevalent in our Southern 
States, and generally known as " break-bone fever." 

Lesions. — (a) The joints, large and small, become red and 
swollen, (b) A cutaneous rash is common, but has no distinctive 
character, (c) General enlargement of the lymphatic glands is 
frequent. The disease rarely being fatal, few or no detailed observa- 
tions regarding the pathologic anatomy are available. 

Diphtheria is an acute, infectious, contagious disease, caused by 
the Klebs-Lbffler bacillus, and characterized by the formation of a 
lalse membrane and by a profound toxaemia. The bacillus is a non- 



DISEASES DUE TO PARASITES 3^ 

motile micro-organism (Plate V, no. 6) which, when grown on blood- 
serum, assumes a great variety of shapes. It is easily cultivated on 
albuminous media in from twelve to sixteen hours, and is fairly resist- 
ant, living for months under favorable conditions. Steam, certain 
poisons, and many other organisms produce a similar membrane, as 
the spirillum and fusiform bacillus of Vincent's angina, 1 and the iden- 
tity of this bacillus with the pseudobacillus of diphtheria, the bacillus of 
scleroderma, and the organisms of ozsena, noma, etc., is believed by 
many, but the subject is still sub judice. As a rule the micro-organ- 
isms do not penetrate below the submucosa at the site of the lesion, but 
in rare or malignant cases they may be found in the blood, the bladder, 
and the internal organs. The fact that they are frequently present in 
the throats of well persons is of great interest. The toxin of the 
bacillus causes ordinary diphtheria, and to the toxon (another poison- 
ous product, having less affinity for antitoxin than the toxin) is due 
the marasmus and paresis which sometimes follows. A lethal dose 
of diphtherial poison is one that is fatal in four or five days to a guinea- 
pig weighing 250 grammes. (Ehrlich.) Normal poison is a solution 
containing 100 fatal doses of the diphtherial poison per cubic centimetre 
(v. Behring), and an immunity-unit (I.-E. of German literature) is 
equivalent to one cubic centimetre of antitoxin capable of neutral- 
izing one cubic centimetre of the normal poison. 2 

Lesions. — (a) The false membrane consists of a fibrinous exudate 
involving the epithelial cells, the whole undergoing coagulation necro- 
sis. It begins early as a slightly raised, opaque, whitish-yellow spot 
on the mucous membrane, and usually grows rapidly, becoming 
thicker, of a grayish or greenish hue, and so firmly adherent to the 
underlying tissues that its removal in the early stages leaves a raw 
bleeding surface. Later it becomes soft, shreddy, and more easily 
detached. The diphtheritic patches may become hemorrhagic, the blood 
infiltrating both the submucous layer and the pseudomembrane, which 
is then a dirty brown or grayish green. When the submucosa and the 
surrounding connective tissues become markedly infiltrated the inflam- 
mation is said to be phlegmonous. ( 1 ) In the nose, the diphtheritic 
membrane, though often slight in extent, may entirely block up the 
nasopharynx. The inflammation may extend to the accessory sinuses, 

1 Lancet, May 13, 1905. 

2 See Oppenheimer, Toxine and Antitoxine, Jena, 1904, for a full account of 
this interesting subject. 



3 I4 POST-MORTEM EXAMINATIONS 

the middle ear, or the membranes of the brain. (2) In the pharynx, 
the exudate is usually first seen on the tonsils. It is liable to extend into 
the mouth, the oesophagus, and even the stomach. Retropharyngeal 
abscess may result. (3) In the larynx, the amount of exudate is 
often very great. It may entirely occlude the air-passages and extend 
to the lungs and bronchial tubes, even to those of the third and fourth 
dimensions, but as it extends it becomes softer and thinner. In this 
form the pharynx may be entirely free from membrane. (4) Cutane- 
ous diphtheria is somewhat less common and the membrane is seldom 
extensive. It is apt to occur about wounds. (5) Growths may occur 
on various other mucous membranes, as the conjunctiva, the 
vagina, in exstrophy of the bladder; and also in the external 
auditory meatus. Paralysis may follow diphtheria of the genitalia, 
even though they alone be affected, (b) Lymphatic glands of the 
neck and often the salivary glands are markedly inflamed, swollen, 
and softened, (c) Bronchopneumonia is apt to occur, small atelec- 
tatic areas of the lung being surrounded by zones of inflammation. 
Should the diphtheritic membrane become gangrenous the process is 
especially liable to extend to the lung. In such cases Klebs-Loffler 
bacilli are usually not found, but cocci of various kinds are present, (d) 
Endocarditis and pericarditis are extremely rare, but parenchymatous 
and fatty degenerations of the muscle-fibres are comparatively com- 
mon. The serous membrane often shows ecchymoses. (e) The 
kidneys always show more or less diffuse inflammation, which may 
be hemorrhagic, and albuminuria is the rule. (/) A peripheral paren- 
chymatous neuritis is not infrequent, (g) An enteritis nodularis is 
described by Orth, in which the follicles and Peyer's patches are 
markedly swollen and hypersemic. Fungoid growths in the oesopha- 
gus sometimes occur. 

Dysentery is an infectious disease endemic in warm countries and 
sporadic or epidemic in temperate regions; it is characterized by 
specific ulcerative lesions of the large intestine. The exciting cause 
of the disease has been much discussed. In certain cases, especially when 
acute, the short motile bacillus of Chantemesse, 1 an organism resem- 
bling both the typhoid bacillus and the colon bacillus, seems to have 



1 Commonly spoken of as the bacillus of Shiga, although described by Chante- 
messe and Widal in 1888. (Presse med., July 23, 1902.) For late information on 
the bacteriology of dysentery, see vol. i of Studies for the Rockefeller Institute; and 
Knox, Jr. Amer. Med. Assoc, July 18, 1903, and December 17, 1904. 



DISEASES DUE TO PARASITES 315 

an etiologic significance. Summer diarrhoea of children has also 
recently been shown to be due to the same organism. The diagnosis 
may at times be made by the agglutinative reaction. In other cases, 
especially where chronic, and where abscesses develop, the Amoeba 
dy sentence (the name suggested by Councilman as more distinctive 
than Amoeba coli of Lbsch) is undoubtedly the exciting cause. This 
protozoon is found in the glairy, bloody dejecta of dysenteric patients, 
and also in the contents of complicating abscesses of the liver. Infec- 
tion is through food and drink, and, some believe, through the air. 

Lesions. — {A) The large intestine, especially the flexures and 
the valvulae conniventes, is the seat of the characteristic lesion. On the 
mucosa are seen sharply defined, projecting nodular thickenings of 
various sizes, in which are cavities filled with a gelatinous pus and 
communicating with the surface of the mucous membrane by small 
openings. A number of such ulcers may communicate, forming larger 
cavities or long sinuous tracts, which undermine the mucosa. They are 
situated chiefly on the folds of the mucous membrane, and lie trans- 
versely to the long axis of the colon. They usually extend through 
the submucous coat only, but sometimes the muscular coats also 
become necrotic, and sloughs of tissue are found in the stools. The 
gelatinous material, consisting of large round swollen cells, red corpus- 
cles, pus-cells, and amoebae, may be wiped from the surface, leaving 
the floor of the ulcer clean. The mucous membrane in the neighbor- 
hood of the lesion is intensely hyperaemic; the blood-vessels may be 
thrombosed, interstitial hemorrhages resulting. The intestinal lymph- 
nodes may be swollen and hyperaemic. In the gangrenous form, de- 
struction is extensive. In more or less chronic cases, the surface of the 
intestine is of a pale rosy or slate color ; the ulcers, in various stages of 
development, are discrete, with thickened callous edges. The necrotic 
process may become circumscribed, and the formation of granulation 
tissue, becoming fibrous, may result in the formation of a bluish pig- 
mented scar. (B) The liver may be normal, but in chronic dysen- 
tery it is often atrophied, and in acute cases it may be congested and 
dark red, or sometimes of a dark or pale yellow color. In the gan- 
grenous form, the liver is usually much enlarged, soft, friable, and 
of a dark color, with numerous small abscesses, probably resulting 
from microbic embolism, disposed among the capillaries. The true 
dysenteric abscesses, more common in the non-gangrenous acute and 
chronic forms, vary in size, and are situated chiefly in the right lobe 



316 POST-MORTEM EXAMINATIONS 

of the liver, near the surface, usually directly beneath the capsule, 
which is slightly thickened at these points. They contain a trans- 
lucent, viscid fluid, composed of a few pus-cells, red corpuscles, broken- 
down liver-cells, a quantity of granular fatty matter, and numerous 
active' amoebae, and have no definite limiting membrane. The solitary 
large tropical abscess is rarely to be found in acute dysentery. 
It is more common in subacute or chronic cases terminating 
in recovery. Usually situated in the right lobe, it is occasionally 
found in the middle, or in the epigastric lobes of the organ. The 
contents, which may amount to six pints, are a homogeneous liquid, 
cream, reddish-yellow, or dark chocolate color — the so-called anchovy 
sauce — and composed of the same elements as the liquid in the smaller 
abscesses described above. Such an abscess may rupture externally, 
or into the lungs, stomach, or intestinal canal. (C) The lungs may 
be the seat of congestion and hypostatic pneumonia. If an hepatic 
abscess bursts into the lung, secondary abscesses should always be 
searched for. (D) The kidneys and spleen are usually normal in 
acute cases, but there may be some congestion and cloudy swelling. 
In chronic cases they are somewhat atrophied. (E) The body appears 
emaciated after a protracted case. The tissues are bloodless and the 
muscles are atrophied. There may be oedema of the lower extremi- 
ties. (F) See also p. 185. 

Erysipelas is an acute contagious disease caused by the Strep- 
tococcus or Diplococcus erysipelatis, and is characterized by an 
inflammation of the skin, which spreads over the surface and may 
extend to the deeper parts. The micro-organisms gain entrance 
through a wound or abrasion, and may be found post mortem in the 
lymph-spaces and the zone of spreading inflammation. Most authori- 
ties consider the organism identical with the Streptococcus pyogenes. 
The writer is familiar with a case in which a wound received from 
operating on a case of empyema gave rise to erysipelas. 

Lesions. — (A) Skin, (i) Erysipelas simplex. In uncomplicated 
forms little more than an inflamed oedema is seen. In severe cases the 
face and scalp are enormously swollen, the eyes are closed, the lips 
cedematous, and the ears thickened. Blebs and vesicles often appear 
on the eyelids, ears, and forehead. (2) Erysipelas ambulans is that 
type of the disease characterized by a rapid spreading from one part 
to another, or by disappearance from one part and appearance else- 
where. (3) Erysipelas phlegmonosum. The fluid contents of the 



DISEASES DUE TO PARASITES 317 

vesicles may become purulent, and thus are formed small cutaneous 
abscesses about the cheeks, forehead, and neck. Large quantities of 
pus may accumulate beneath the scalp. The inflammation may extend 
to the intermuscular fascia, and is then likely to be gangrenous, par- 
ticularly when following hemorrhagic contusions. This form, besides 
being the cause of acute purulent oedema, may result in emphysema- 
tous inflammation from associated gas-producing germs. (B) The 
cervical lymph glands are enlarged, but this is masked by the 
oedema. (C) The lungs often contain infarcts, usually septic in 
character. Pleurisy is relatively common. (D) In cases which end 
fatally, endocarditis ulcerosa is particularly frequent, and septic peri- 
carditis comparatively so. (E) The kidneys may show septic 
infarcts. True nephritis is rare, though albuminuria is quite constant. 
(F) The spleen may be the seat of septic infarction. (G) The 
liver may undergo acute atrophy. (H) Septiccemia is not rare. 

FOOT-AND-MOUTH DISEASE (STOMATITIS APHTHOSA EPIZOOTICA) 

is an acute contagious disease occurring most frequently in cattle and 
sheep, but found also in persons, who contract it from diseased 
animals, or through the milk of cows with infected udders. Loffler 
and Frosch consider it to be due to an organism so minute that it 
passes through the finest filters and is invisible with the best of our 
present microscopes. Some recent cases in man have been reported 
from Rhode Island and Connecticut. 

Lesions. — (A) On the lips, cheeks, or pharyngeal mucous 
membrane the characteristic lesion begins as a small vesicle, at first 
clear, but later grayish. It may also be found on the udders and on 
the feet, usually appearing after the eruption in the mouth. When the 
vesicle reaches a diameter of from one and a half to two centimetres 
it bursts, leaving a shallow ulcer, with oval, circular, or irregular 
edges. The affected mucous membranes are inflamed, swollen, and 
cedematous, and there is a considerable exudate. A colored illustra- 
tion of the bovine tongue and hoof lesion is seen in Kitt's Atlas der 
Thierkrankheiten (1896). (B) The parenchymatous organs show 
oedema, hemorrhagic infiltrations, and fatty changes. 

Frambgesia (Yaws) is a contagious tropical disease of the skin, 
presumably of microbic origin, having an indefinite period of incuba- 
tion and characterized by the presence of dirty or bright red raspberry- 
like tubercles. 



3I g POST-MORTEM EXAMINATIONS 

Lesions. — The cutaneous eruption begins as a papule, usually at the 
site of an old wound. In a few days the papules are scattered over the 
body; they rapidly enlarge and become tubercles, which are generally 
circular in shape, and vary in size from that of a pin's head to a small 
apple. The epidermis splits or cracks, exposing a raw granulating 
surface, which rarely ulcerates. A secondary eruption occurs, which 
is fungoid, monomorphous, and asymmetrical. There are no recorded 
lesions of the mucous membranes, the viscera, the eye, or the 
nervous system. Frambcesia is by some supposed to be a modified 
form of syphilis, and a spirillum has been found which will require 
further study to classify it. 

Glanders (Equinia) is essentially a chronic necrotic alteration 
due to the Corynebacterium mallei, 1 especially affecting the nasal 
mucous membranes (glanders proper) and the skin and subcutaneous 
tissues in the -form of nodules (farcy) ; it occurs most frequently in 
horses and asses, but may be transmitted to man, as by accidental 
laboratory inoculation and by hostlers washing themselves with a 
sponge previously used upon an animal affected with this disease. 
Mallein (or morvin), which is prepared like tuberculin, contains an 
endotoxin, having distinct diagnostic, but practically no therapeutic 
uses. Stalls in which affected animals have been quartered should, 
after the removal of the carcass, be thoroughly cleansed, disinfected, 
and then whitewashed. Two forms of the disease are recognized : — 

I. Glanders. — (A) The mucous membrane of the nose and 
upper respiratory tract is most frequently affected. The charac- 
teristic lesion is a node or tubercle, which is at first spherical, later 
becomes flattened, and then breaks down, presenting more or less exten- 
sive ulcerations which tend to run together and thus give the part a 
honey-combed appearance. The mucous membrane is swollen, of 
a purplish or dark red color, and there is considerable exudate from 
the ulcerating surfaces. The floor of the ulcers is covered with yellow 
necrotic tissue. Such ulcers are frequent about the turbinated bones. 
Chronic glanders usually occurs in the nose, and is often taken for 
chronic coryza. (B) The lungs may become involved by extension, 
the most prominent lesion being a catarrhal pneumonia, in which the 
diseased areas show a marked tendency to break down, with the forma- 

1 For a description of this micro-organism, see p. 386. 



DISEASES DUE TO PARASITES 3^ 

tion of abscesses, though calcification sometimes takes place. 1 (C) 
An eruption of papules, which soon become pustular, frequently 
appears upon the face and about the joints. Caseous nodes and 
patches of suppuration are sometimes found in the periosteum and the 
synovial membranes. (D) The cervical glands are usually much 
enlarged. (E) The gastrocnemii sometimes contain a dirty yellow, 
pasty mass of pus, probably due to glanders. 

II. Farcy. — (a) The acute form is of the nature of a phleg- 
monous inflammation at the point of inoculation. The process may be 
very extensive, leading to rapid suppuration of the surrounding parts, 
and subcutaneous enlargements (" farcy buds") along the course of 
the lymphatics. Metastasis to the surrounding tissues is common, 
accompanied by the formation of abscesses in the muscles, (b) In 
chronic farcy, localized tumors are found in the skin, the subcutane- 
ous tissue, and the muscles. These tumors result in abscesses, and 
may form deep ulcers. 

Glandular Fever is an acute infectious disease of childhood, 
occurring between the ages of one and ten years, and bacterial in 
origin. It is rarely fatal. 

Lesions. — (A) Marked enlargement and softening of the cer- 
vical lymphatic glands is characteristic. Suppuration seldom 
occurs, and the adjacent skin and mucous membrane show no marked 
changes. (B) The throat may be congested and the tonsils are 
usually swollen. (C) The spleen, liver, and even the mesenteric 
glands are at times enlarged; and in some cases the axillary and 
inguinal glands are involved. 

Gonorrhoea is a specific infectious disease, characterized by an 
exudative inflammation, and due to the presence of the Gonococcus 
of Neisser (1879). (Plate V, no. 1.) 

Lesions. — (a) In general infection the organism has been found 
in the blood, which after death may be fluid or semi-fluid, and tarry- 
black in color, (b) Local infection produces in the male urethritis, 
periurethral abscesses, prostatitis, proctitis, etc., while in the female 
may be found vaginitis, end cervicitis, inflammation of the Bartho- 
linian glands, metritis, salpingitis, ovaritis, peritonitis, cystitis, 
pyelitis, etc. (c) Arthritis (gonorrhceal rheumatism) may occur; it 
is a synovitis which rarely becomes purulent. The inflammation is acute, 

1 Cattell, Trans. Phila. Path. Soc, 1893-95, vol. xvii, p. 253. 



320 



POST-MORTEM EXAMINATIONS 



periarticular, affects several joints, and extends along the sheaths of 
the tendons, (d) Conjunctivitis is not rare. It occurs most frequently 
in the new-born, leads to thickening and ulceration of the conjunc- 
tivas, and may give rise later on to various forms of internal infection. 
Erosions or entire destruction of the cornea may result. The skin of 
the lids may be destroyed. Iritis sometimes occurs, (e) An acute 
form of single or ulcerative endocarditis occurs, from which pure cult- 
ures of the Gonococcus have been made. At times, pericarditis and 
myocarditis have been reported, and rarely pleurisy. All these lesions 
show a marked tendency to suppurative change. 

Hydrophobia (Lyssa, Rabies) is an acute disease communi- 
cated only by direct inoculation, the toxins of which by their action 
on the higher nervous centres produce the characteristic convulsions. 
Negri, 1 of the University of Pavia, has described certain bodies found 
in the brain, spinal cord, and ganglia of animals dead of hydrophobia. 
He believes, and his work has been confirmed by other Italian investi- 
gators, that these bodies are parasites, probably protozoa, and that they 
have an etiologic relation to hydrophobia, though he admits that this 
has not been proved. Other investigators describe a bacillus as the 
cause of rabies. Pasteur treatment may now be had throughout the 
civilized world, it having been found practicable to convey the inocu- 
lating material a long distance. 

When a dog that is supposed to be mad has bitten a human being, 
the animal should not be killed at once, but should be permitted to 
live and kept under close observation until sufficient time has elapsed 
to permit unmistakable signs of rabies to develop, if such be present. 
The dog is then killed and its body sent to a competent bacteriolo- 
gist for microscopic study and inoculation experiments on rabbits. 
While the recent so-called rapid method of diagnosing rabies is not 
absolutely characteristic of the disease, it affords a most valuable 
early means of tentative diagnosis, to be confirmed or disproved by 
subsequent animal inoculation. The method employed is that of Babes, 
van Gehuchten, and Nelis, and is as follows : 2 Several intervertebral 
ganglia or a portion of the bulb are put at once into absolute alcohol, 
in which they are left for twenty-four hours. They are then trans- 
ferred for one hour to a mixture of absolute alcohol and chloroform, 



1 Zeitschr. f. Hyg. u. Inf. Krank., vol. xliv, no. 3. 

2 Ravenel and McCarthy, Proc. Path. Soc. Phila., 1901, p. 93. 



DISEASES DUE TO PARASITES 



321 



next put for one hour into pure chloroform, then for one hour into a 
mixture of chloroform and paraffin, and lastly for an hour into pure 
paraffin. The sections are put in the oven for a few minutes, then passed 
through xylol, absolute alcohol, and ninety per cent, alcohol, after 
which they are stained for five minutes in methylen blue, according to 
Nissl's formula, differentiated in ninety per cent, alcohol, dehydrated 
in absolute alcohol, and cleared in essence of cajuput and xylol. 
Other methods of preparing the tissues may be used, such as rapid 
fixation with ten per cent, formalin, subsequent freezing, and stain- 
ing with hematoxylin and eosin. The microscopic changes are chro- 
matolytic and capsular. The " rabic tubercle" of Babes consists in 
the pericellular accumulations of the embryonal cells described by 
Kolesnikoff. The prolongations of the cells of the bulbar nuclei are 
shortened, the nuclei are altered or even obliterated, and the nerve- 
cells are invaded by the embryonal cells and small corpuscular 
elements. Atrophy, invasion, and destruction of the nerve-cells of the 
intervertebral and plexiform ganglia of the pneumogastric take place 
by cells newly formed from the capsule, which appear between the cell 
body and its endothelial capsule; in advanced cases the field even 
resembles an alveolar sarcoma. 

Lesions. — (A) The cerebrospinal system shows congestion of 
the blood-vessels, and minute hemorrhages, most numerous in the 
medulla. (B) The pharynx, larynx, trachea, larger bronchi, 
lungs, oesophagus, and stomach show the mucous membrane con- 
gested, and not infrequently covered with blood-stained mucus. 
(C) The virus has been shown by experiments to exist abundantly 
in the spinal cord, brain, and peripheral nerves, but it has not 
been found in the liver, spleen, and kidneys. 

Influenza (Grippe) is an acute contagious epidemic disease, due 
to a bacillus, discovered by Pfeiffer in 1892, and is characterized by 
abrupt onset, great depression, and many sequelae. The Bacillus 
influenza is found especially in the nasal and bronchial secretions, but 
may be present in discharges from the conjunctiva, ear, etc. It is one 
of the smallest organisms known, non-motile, aerobic, and stains well 
with Loffler's methylen blue. On culture media it grows best in the 
presence of haemoglobin, and of certain other organisms (symbiosis). 
It shows polar staining by one to ten solution of carbol fuchsin. 

Lesions. — I. Respiratory form. — An acute inflammation of the 
mucous membrane of the upper respiratory tract and the bron- 

21 



222 POST-MORTEM EXAMINATIONS 

chial tubes takes place. Lobular pneumonia is common, and is prob- 
ably due to a mixed infection. Pleurisy is more rare, but may occur 
and lead to empyema. Tuberculosis is apt to be exaggerated by 
an attack of influenza; and diffuse bronchiectasis has followed it. In 
some epidemics, accumulations of pus in the nasopharynx are exceed- 
ingly common. 

II. G astro-intestinal form. — The inflammation extends to the 
mucous membrane of the stomach and intestines. It is seldom of 
a severe type. The spleen is usually enlarged. The recent large 
number of cases of appendicitis is attributed by some to the wide- 
spread prevalence of this disorder. 

III. Nervous form. — Mild degrees of meningitis and encephalitis 
are not uncommon. Abscesses of the brain have occurred in severe 
acute cases. 

Complications. — (a) Acute diffuse nephritis is quite frequent. 
(b) Orchitis, (c) Endocarditis, pericarditis, and thrombosis have 
been reported, (d) Occasionally purpura and herpes are seen, (e) 
Iritis and catarrhal conjunctivitis may occur. 

In an autopsy on a child dying from meningitis following the 
grippe, Dr. Kneass in 1895 isolated for me the influenza bacillus. 

Leprosy is a chronic infectious disease due to the leprosy bacillus, 
and is characterized by the formation of nodes or nodules, and by 
degenerative changes in the nerves. The Mycobacterium leprce mor- 
phologically resembles the bacillus of tuberculosis. It stains more 
readily, however, is more easily decolorized, and is present in far 
greater numbers in the lesions which it causes. Van Houtum * 
claims to have cultivated this organism successfully, while several inves- 
tigators have recently given promising reports of the discovery of a 
curative serum. The organisms have been found in mosquitoes and 
fleas. That leprosy may be cured, so far at least as to check the 
advance of the lesions, is now an established fact. Hutchinson claims 
that the disease is contracted from fish. 

Lesions. — I. Tubercular form. — (A) The primary lesion is found 
most frequently in the skin of the face, and on the surfaces of the 
knees, the elbows, the hands, and the feet. It starts as a small 
red spot in the corium, which may become pigmented or colorless, and 
which either disappears or gives rise to the formation of inflammatory 

1 Journal of Pathology and Bacteriology, September, 1902, p. 260. 



DISEASES DUE TO PARASITES 323 

nodules, somewhat soft in consistency, and of a brownish-red color, 
resembling a strawberry. This form of the disease is apt to be exceed- 
ingly chronic, the surrounding tissues showing marked fibroid changes. 
The tubercles at times become swollen through fatty disintegration. 
Extensive ulceration is common, and pigment-spots often occur on the 
face. (B) The conjunctivae and other mucous membranes, partic- 
ularly of the nose, the cornea, and the larynx, may be similarly 
involved. (C) The lymph glands are hard, swollen, and yellow. 
(D) Nephritis occurs. (E) The liver, spleen, and testes show 
hyperplasia of the connective tissue. 

II. Anesthetic form. — (A) The peripheral nerves are gradu- 
ally involved by the leprous process, which first causes a perineuritis, 
then obliteration of nerve-tissue, and necrosis and ulceration. Exten- 
sive loss of substance occurs, as of fingers, toes, or even of limbs. 
There is great loss of hair, and the face often becomes markedly 
deformed by the ravages of the disease. (B) The involvement of the 
larynx, or aspiration pneumonia, often causes death. (C) The 
infection of the spleen is shown by the presence of large ovoid 
mononuclear cells, usually vacuolated and containing many of the 
bacilli. (D) The bone-marrow is often the seat of granulomatous foci 
containing bacilli. Ulceration of the soft parts and necrosis and 
osteomyelitis of the underlying bone may occur. 

Malta Fever (Mediterranean or Undulant Fever) is a 
chronic disease, resembling in its clinical course typhoid fever and 
malaria; it occurs most frequently in the Mediterranean region. It 
is due to the Micrococcus melitensis, which organism may be isolated 
from the urine and the blood. It would seem to be introduced into man, 
at times, by goat's milk. Young and previously healthy adults who are 
unacclimated are most frequently attacked, and British garrisons suffer 
seriously from the disease. It occurs in our new possessions, and 
soldiers and sailors returning home may bring the affection with them. 
The agglutinative reaction can be obtained with the micrococcus and 
the blood of a patient affected with the disease. 

Lesions. — The visceral changes are those common to all infectious 
diseases exhibiting high temperature. (A) The small intestine 
is usually anaemic except in the upper part, where it may be intensely 
congested. The mesenteric glands show little change. (B) The 
spleen is much enlarged and is dark in color; its pulp is soft and 
friable, and sections show an increase in the lymphoid elements. The 



3 24 POST-MORTEM EXAMINATIONS 

average weight in such case is eighteen ounces. The micrococci are 
found in large numbers in the organ. (C) The liver is congested, 
and its surface on section is pigmented. (D) The kidneys are usually 
congested, and may be slightly hemorrhagic. 

Sequela. — Swelling of the joints, anosmia, orchitis, and neuralgia. 

Measles (Morbilli, Rubeola) is a markedly contagious disease, 
attended with a skin eruption and with catarrh of the mucous mem- 
branes. It is due to a micro-organism, the identity of which is not 
yet definitely settled. Lesage, Canon and Pielicke, Czajkowski, and 
others have described organisms as causes of the disease. This affec- 
tion, as well as scarlet fever and German measles, must be distinguished 
from Duke's fourth disease, which has characteristics common to all 
three disorders, and from erythema infectiosum, recently brought to 
our attention anew by Shaw. There has been recently described a 
so-called " fifth disease." 

Lesions, chiefly those of its complications and sequelae. — (y4)The 
skin, especially about the face, may be swollen and slightly cedematous, 
and may show the remains of the characteristic rash, especially in the 
hemorrhagic type. Desquamation, when present, is in the form of 
fine branny scales. (B) The lungs show evidence of bronchitis, and 
almost invariably lesions of bronchopneumonia, with areas of collapse ; 
less frequently lobar pneumonia may be found. The bronchial 
glands are swollen. Pleurisy is less common. (C) The gastro- 
intestinal mucosa is usually hyperaemic. Peyer's patches are fre- 
quently swollen, sometimes markedly so. Colitis may occur. (D) 
Severe stomatitis, cancrum oris, ulcerative vulvitis, or gangrene of 
the genitalia may develop in debilitated infants. (E) Laryngitis, 
severe angina, diphtheria, and rheumatism sometimes complicate 
measles. 1 (F) In the middle ear catarrhal inflammation, which may 
go on to abscess formation and perforation, is not uncommon. 

Sequelce. — (a) Tuberculosis, either caseous or miliary, is the most 
important of the sequelae, (b) Severe forms of conjunctivitis and 
ulcer of the cornea are not uncommon, (c) Cloudy swelling of the 
organs, (d) Nephritis and arthritis are exceedingly rare, (e) Dis- 
seminated sclerosis is rare. 

Mumps (Parotitis) is an acute, infectious, contagious disease, 
probably due to a diplococcus or a diplobacillus, and characterized by 

1 Medical Record, June 17, 1902. 



DISEASES DUE TO PARASITES 325 

a marked cellular infiltration of the parotid glands, with metastases to 
the ovaries and mammary glands in females, and to the testicles 
in males. It occurs chiefly in childhood or adolescence. Adults or 
very young infants are seldom attacked. Uncomplicated mumps is 
rarely fatal. 

Lesions. — {A) The parotid glands are markedly enlarged, but 
have no tendency to suppurate or to become fibroid. (B) Orchitis 
occurs before puberty, but rarely. In such cases a mucopurulent dis- 
charge is often seen in the urethra. Atrophy and imperfect develop- 
ment may follow. (C) Vulvovaginitis may occur in girls, and cases 
of resulting atresia of the vagina have been reported. 

Complications. — Meningitis, acute mania, endocarditis, gangrene, 
and optic atrophy are the most important. Arthritis and chronic 
hypertrophy of the affected glands have occurred. 

Paratyphoid Fever. — See p. 181. 

Pertussis (Whooping-cough) is an infectious disease charac- 
terized by a convulsive cough ending in a long inspiration, often 
followed by spasmodic expirations. Koplik believes the disease to 
be due to a small bacillus. 

Lesions, which are, however, not characteristic. — (A) Catarrhal 
inflammation of the entire respiratory tract is often found. The 
bronchial glands are enlarged. (B) The eyes may be injected, or there 
may be distinct ecchymosis. (C) On the forehead petechias may 
appear. (D) Anaemia is common. (E) An ulcer under the tongue 
is often found. 

Complications. — The most important are subdural hemorrhage, 
pulmonary emphysema, pneumothorax, and bronchopneumonia, which 
is usually tuberculous. 

Plague 1 is an acute, infectious, contagious, epidemic disease, due 
to the Bacillus pestis. It occurs usually in the Far East, where in 
India alone one million persons are now dying annually from the 
disease, but is at present (1906) widely distributed over the earth's 
surface. In the East a heavy rat mortality is the precursor of the 
disease. The epizootic arises at the season of the year when young 
rats are most numerous, which being bitten by fleas, especially the 

1 The bacteriology, morbid anatomy, histopathology, and literature of plague are 
well considered in Herzog's article issued by the U. S. Government, Dept. of the 
Interior, Manila, October, 1904, and in Simpson's work (1905), Cambridge. Both 
volumes are illustrated. 



~ 2 £ POST-MORTEM EXAMINATIONS 

Pulex cheopsis, infected with the bacillus, give rise to the disease. 
Cats show a septicemic form of plague. 1 The bacillus was discovered 
independently by Kitasato and Yersin. It is a short rod with rounded 
ends, and is found in the blood, glands, viscera, faeces, and urine. 

Plague is characterized by marked glandular enlargements which 
tend to suppuration, and by a general septic condition, hemorrhage, 
and carbuncles. Plague must be distinguished from puerperal fever, 
septicaemia, pyaemia, smallpox, influenza, cerebrospinal meningitis, 
diphtheria, erysipelas, measles, gonorrhoea, syphilis, mumps, malaria, 
scrofulous glands, Hodgkin's disease, etc. In a case (1901) of a 
Philadelphia Chinaman suspected of having the plague, the writer 
found almost complete occlusion of the prepuce, with a discharge con- 
taining the Gonococcus, and in the suppurating bubo a fat diplobacillus 
which did not stain by Gram's method. 

Lesions. — I. At the point of inoculation, which is usually on the 
lower limbs, there may appear a small spot {plague corpuscle) which 
soon becomes a vesicle and then a pustule. II. In the bubonic form, 
the inguinal glands become swollen following the primary inocula- 
tion, succeeded in order by swelling of the axillary, cervical, 
popliteal, and other glands in the body. The diseased glands swell 
rapidly and are at first tense and firm to the touch, but soon undergo 
a suppurative change; in rare cases gangrene ensues. It is the peri- 
glandular tissue that becomes ©edematous and undergoes septic 
inflammation. Hossack found no buboes in thirty per cent, of his cases 
in Calcutta in 1900. III. In the carbuncular form, carbuncles may 
develop in the skin of the legs, lips, and back. Subcutaneous hemor- 
rhages are very common, and hemorrhages may also occur in the 
mucous membranes. IV. In the meningeal form, the central 
nervous system, especially the brain, is deeply congested. The 
cerebral substance may become softened, and the blood-vessels, 
especially the veins, are engorged. V. In the pneumonic form, the 
lungs are deeply congested, especially posteriorly, and are at times 
the primary seat of the disease. VI. In the septic form, the peri- 
cardium contains an excess of blood-stained fluid. The right heart 
is dilated with black, imperfectly coagulated blood, and the whole 
venous system is engorged. The heart-muscle is pale and some- 
what softened. VII. In the intestinal form, the stomach and small 

1 Lancet, April 22, 1905. 



DISEASES DUE TO PARASITES 327 

intestine contain blood or blood-stained fluid. There may be ulcera- 
tion, but the Peyer's patches are not affected. The spleen is greatly 
enlarged in all cases. VIII. The dorsum of the tongue is coated, 
but the edges, the tip, and often the median raphe remain pink and 
clean, sometimes, however, becoming red and dry. (Hossack.) 

Pneumonia (Pneumonitis), except when qualified by a proper 
descriptive adjective, is an indefinite term applied to various inflamma- 
tions of the lung tissue, the organisms especially concerned being the 
Diplococcus pneumonice of Frankel, the Bacillus pneumonic? of Fried- 
lander, the B. tuberculosis, Actinomycetes, B. iniluenzce, B. pestis, 
C orynebacterium diphtheria , B. typhosus, B. coli communis, Micro- 
coccus catarrhalis, Streptococcus pyogenes, Staphylococcus pyogenes, 
and the virus of syphilis. A special pneumonia commission in America 
is trying at the present time to elucidate some of the most difficult 
problems of pathology by a painstaking study of pneumonia. 

Croupous (lobar or acute) pneumonia is an infectious and mildly 
contagious general disease occurring with a sudden onset, in which 
solidification of pulmonary tissue takes place as a localizing lesion. 
Osier considers the mortality to be one in four persons affected. It 
is due in most cases to the Diplococcus pneumonice (Pneumo coccus) , 
less frequently to the Bacillus pneumonice and Aspergillus bronchialis, 
and is characterized by an exudative inflammation of the whole or part 
of one or both lungs, the right lower lobe being most frequently 
affected, and by a more or less profound toxaemia. Males are more 
frequently affected than females. The Pneumococcus, shown by Stern- 
berg to be normally present in a large proportion of healthy persons in 
mouth, nose, and pharynx, readily demonstrated in cover-glass prep- 
arations stained by Gram's method, is found in the bronchial secre- 
tions and in sections of the affected lung, in pairs surrounded by a 
lanceolate capsule. For differentiating from streptococci it should be 
grown on agar plates containing blood. Mice have recently been 
considered as one of the sources of this disease. 

Lesions. — (A) Lungs. The pathologic findings show three dis- 
tinct stages : ( 1 ) The stage of engorgement, which lasts about twenty- 
four hours. The lungs are heavier, firmer, more solid, and redder than 
normal. They still crepitate, though not so distinctly as does healthy 
tissue. The cut section exudes a frothy serum, and will partially 
float. (2) The stage of red hepatization, which lasts from one to four 
days. The affected lobe (or lobes) is larger, heavier, and firmer 



328 POST-MORTEM EXAMINATIONS 

than normal, and is of a deep red color. It is airless, does not collapse 
on exposure to the atmosphere, and excised portions sink in water. 
If such a lung be examined several days after its removal from the 
body, the appearance is changed by autolysis to that of the third stage, 
or even signs of apparent resolution may present themselves. On sec- 
tion the lung is dry, reddish brown, and exceedingly friable. Careful 
inspection shows that the cut surface is distinctly granular, due to 
fibrinous plugs in the smaller bronchi and blood-vessels, which are 
lighter in color than the intensely red tissue, and which can be scraped 
off with a knife, together with a reddish viscid serum. Such fibrinous 
masses may extend into the larger tubes and thus form perfect casts. 
The bronchi may contain a mucous secretion tinged with blood, or 
more rarely the tenacious mucus so characteristic of pneumonic sputum. 
The microscope reveals in the alveolar meshes fibrinous threads, epithe- 
lial cells which have undergone hyaline and necrotic changes, leucocytes, 
fed blood-cells, micro-organisms, etc. Sections taken from the central 
portion of the lung show more cellular elements, while those from the 
surface are richer in fibrin, showing that the infection probably takes 
place from the bronchi. The pleural surface of the lung is covered with 
a more or less extensive layer of fibrin, — the so-called bread-and-but- 
ter pleurisy, — which forms a false membrane that contrasts markedly 
with the smooth shiny appearance of the unaffected portions of the 
lung. The surface may retain the impressions of the ribs. In this 
connection it is well to remember that there is a pneumonic form of 
plague and of several other infectious fevers. (3) In the stage of 
gray hepatization the color varies from a reddish brown to a grayish 
white, grayish yellow, or greenish tint. The surface is more moist, 
the exudate more turbid, the granules less distinct, and the pulmonary 
tissue still more friable. The exudate is softened, and the Pneumo- 
coccus is usually no longer to be demonstrated. The cell-elements are 
disintegrated and prepared for absorption. Gray and red hepatization 
may coexist in the same lobe, giving a mottled appearance to the cut 
surface. The process may terminate in ( 1 ) liquefaction, absorption, 
and resolution; (2) suppuration, the lung being then an airless, firm, 
regular gray or red mass; abscesses should always be examined for 
the tubercle bacillus; (3) gangrene; (4) fibroid changes or carnifi- 
cation. 1 (B) The bronchial glands are swollen, soft, and hemor- 

1 For comparison of the lung changes in croupous and catarrhal pneumonia, 
see p. 157. 



DISEASES DUE TO PARASITES 



329 






rhagic, and there may be oedema of the mediastinal tissues. (C) 
The overlying pleura is inflamed, with more or less extensive 
exudate, which may be serous, fibrinous, or more rarely purulent. (D) 
The heart shows the left cavities nearly or quite empty, the right dis- 
tended with firm, tenacious coagula. Pericarditis is not infrequent 
with left-sided pneumonia, and is most common in children. Endocar- 
ditis is more common, and may be malignant and associated with 
meningitis. Myocarditis is rare. (E) The spleen is enlarged in 
many cases. (F) The kidneys and liver show cloudy swelling or 
acute parenchymatous changes. The hepatic veins are often engorged. 

Complications. — Otitis media, conjunctivitis, and arthritis are not 
unusual in children. Severe and often fatal toxcemia may develop 
with a comparatively slight lesion in the lung. Orchitis, purulent syno- 
vitis, jaundice, croupous gastritis, colitis, meningitis, endocarditis, 
empyema, and peritonitis may also occur. 

Pyemia and Septicemia are systemic hematogenous infections 
characterized by the distribution of pyogenic organisms and their 
toxins. The occurrence of thrombosis, followed by the separation of 
infectious emboli and by abscess formation in various parts of the body, 
are the distinctive features of pyaemia. The organisms gain entrance to 
the circulation from any infected wound ; the point of introduction may, 
however, be quite undetermined. The post-mortem appearances vary, 
as there may even be absence of gross lesions. 

Lesions. — Rapid post-mortem decomposition is the rule. Conges- 
tion of all the organs, passive hemorrhages, and enlargement of the 
spleen and of the intestinal lymph glands may occur. Purulent 
inflammation of serous membranes, and of the tissues about joints, is 
sometimes found. 

Relapsing Fever is an acute epidemic contagious disease due to 
the Spirochceta obermeieri, and is characterized by paroxysms of fever 
followed by remissions and relapses. The disease disappeared in 1869 
to reappear in 1905. The specific organisms, which may reach 40 
microns in length, are exceedingly motile, and are found in the blood 
only during the paroxysms of fever, retreating later to the spleen and 
other blood-making organs. Transmission would seem to take place 
especially by the bite of the bedbug, in which insect the organisms may 
remain alive for several weeks. Monkeys are capable of inoculation 
with the disease. The organisms are rarely found post mortem. 
Geese, chickens, and cattle at times have a somewhat similar affection. 



330 POST-MORTEM EXAMINATIONS 

Lesions, which are not characteristic or constant. — (A) The 
skin and tissues are frequently jaundiced. (B) The spleen, if 
death occurs during the paroxysm, is large and soft, and the pulp is 
purple. At times it may appear variegated on section, due to the 
areas of necrosis and fatty degeneration. Infarcts are not uncommon. 
The follicles are enlarged and often obliterated, though they may be 
gray or whitish yellow in color. (C) The heart is flabby, of a pale 
dirty-gray color, and very friable. (D) The liver is more acutely 
enlarged in this than in any other infectious fever. Its color is a 
uniform gray-red. Fatty degeneration may be marked. (E) The kid- 
neys may retain their normal weight. The renal parenchyma is soft and 
flabby; the cortical substance is increased and shows cloudy swelling. 
Hemorrhagic spots or lines radiating to the pyramids are often 
observed. (F) The lungs may be the seat of pneumonic infiltra- 
tion, bronchitis, or bronchiectasis. (G) The stomach and bile 
ducts show catarrhal inflammation. (H) Hyperplasia of the bone- 
marrow has been found. 

Complications. — Pneumonia is frequent. Rupture of the spleen, 
nephritis and hcematuria, and in certain epidemics ophthalmia, may 
occur. Abortion usually takes place. (Osier.) 

Rheumatism is a disease which occurs subsequent to exposure, or 
to indiscretions in diet, and has been variously regarded as due to a 
Diplococcus rheumaticus (London Pathological Society), attenuated 
cultures of Staphylococcus aureus, and a bacillus. 

I. Acute form,:- — Lesions. — (A) The affected joints are swollen, 
tense to the touch, and somewhat hypersemic. The fluid in the joint 
is turbid, and contains albumin, leucocytes, and a few flakes of fibrin, 
but rarely pus. There may be slight erosion of the cartilages. (B) 
On the fingers, hands, and wrists are found rheumatic nodules, 
varying in size from a small shot to a large pea. They may also occur 
about the elbows, knees, spines of the vertebra, and scapulae. 

Seqnelce and complications. — (a) Endocarditis occurs in about 
sixty per cent, of all cases. The verrucose variety is most common, and 
the mitral valve is most often involved, (b) Pericarditis may occur, 
with or without endocarditis. It may be fibrinous, serofibrinous, or, 
in children, purulent. (c) Myocarditis occurs most frequently in 
association with endopericarditis. It leads to weakening and dilata- 
tion of the heart-muscle, and is the most common cause of sudden death 
in rheumatic fever, (d) Pleurisy and pneumonia occur in about ten 



DISEASES DUE TO PARASITES 331 

per cent, of all cases, (e) Meningitis is extremely rare. (/) Purpura 
may be present, (g) Anaemia is one of the most common sequelae. 
(h) Iritis, tonsillitis, pharyngitis, and nephritis occur. 

II. Chronic form: — Lesions. — (A) The synovial membranes 
are injected. There is usually not much effusion. The capsules, liga- 
ments, and sheaths of the tendons are thickened. There may be 
erosion of the cartilages. As a result of these changes, the joints are 
often deformed and ankylosis may occur. (B) Atrophy of the 
muscles, especially about the joints, frequently follows. (C) Valvu- 
lar lesions of the heart, due to sclerotic changes, are of common 
occurrence. 

Rubella (Rotheln, German Measles) is an infectious disease 
usually attacking adults, and rarely fatal in uncomplicated cases. 

Lesions. — (A) The rash on the skin is the only distinctive lesion, 
and this may fade entirely after death. The skin may be slightly 
stained after the eruption. (B) Lymph glands are usually swollen, 
especially those of the neck. 

Complications. — Pneumonia and colitis occur, but rarely. 

Scarlet Fever is an acute infectious disease, characterized by a 
more or less severe angina, a scarlet punctate rash, and febrile 
symptoms. The majority of cases occur before the tenth year, although 
adults are not exempt. F. B. Mallory x describes a protozoon found 
during the disease in the epithelial cells of the skin, tongue, and super- 
ficial lymph-vessels, and the spaces of the corium. It has never been 
found alone, but always associated with streptococci. Cocci are fre- 
quently found in the throat lesions and in the blood. Class, of Chicago, 
claims to have isolated a specific coccus, which has also been described 
by Baginsky. 

Lesions. — (A) Rigor mortis is usually well marked, and decom- 
position may set in early and develop with exceptional rapidity, cada- 
veric lividity usually appearing before death. (B) The blood is dark 
in color, thin, and coagulates imperfectly. The vessel walls are usually 
stained. (C) The skin rarely shows after death a trace of the rash, 
except in the hemorrhagic form. (D) In the throat follicular ton- 
sillitis, diphtheritic membrane, or suppuration may be present. Punc- 
tate hemorrhages, especially about the mouth, are always observed. 
(E) In the gastro-intestinal tract catarrhal inflammation of the 



1 Mallory, Jr. Med. Research, 1904, vol. x. 



2^2 POST-MORTEM EXAMINATIONS 

mucous membrane is not uncommon. The follicles of the small intes- 
tine are swollen, red, and may even be hemorrhagic. (F) Intense 
lymphadenitis with much inflammatory oedema is found in the neck 
in severe cases. This may lead to suppuration or even gangrene, and, 
in rare cases, to ulceration of the carotid artery and fatal hemorrhage. 
(G) The kidney lesions are most important. Acute diffuse nephritis 
is present in a majority of cases. It is frequently of the glomerular 
type and may be hemorrhagic. This lesion is not infrequently followed 
by the changes observed in chronic parenchymatous nephritis. The 
toxin seems to act especially and quickly on the epithelial cells of the 
kidney. In one of my cases, death in convulsions occurred twenty-four 
hours after the onset of vomiting, and without the appearance of 
any rash. The diagnosis was confirmed by the fact that a sister was 
subsequently attacked by the disease. (H) Endocarditis, which may 
be either simple or malignant, is not infrequent. Pericarditis and 
myocardial changes are less common. (/) The spleen is often 
enlarged, and shows the changes which characterize acute splenic 
tumor. (/) Hemorrhages into the subserous tissues beneath the peri- 
cardium, endocardium, and pleura are quite frequent. There is 
more or less cloudy swelling of all the organs. 

Complications. — (a) Nephritis is the most important. The urine 
is small in quantity, has a high specific gravity, is cloudy, and is of 
a dark blood-color. It contains a large amount of albumin, free blood, 
and epithelial cells, with hyaline and epithelial tube-casts. (Edema may 
be slight or marked; in a few cases oedema of the glottis has caused 
sudden death, (b) Heart complications are next in importance. There 
may be endocarditis, pericarditis, or myocarditis. (c) Catarrhal 
pneumonia, more rarely croupous pneumonia, or pleurisy may occur. 
(d) Middle-ear involvement may lead to thrombosis of the lateral 
sinus, meningitis, abscess of the brain, or necrosis of the middle ear 
en masse, (e) Adenitis may result, involving most frequently the 
glands of the neck. There may be great destruction and loss of tissue. 
Retropharyngeal abscess is not uncommon. (/) Arthritis of a rheu- 
matic type, or more closely resembling the gonorrheal variety, may be 
found. In the latter affection, only one joint is involved and suppura- 
tion may supervene. (g) Gangrene of the legs, and noma have 
followed scarlet fever. 

Scleroderma is an acute or chronic disease due to an organism 
of the type of the Bacillus pneumonice and like the one found in ozcena, 



DISEASES DUE TO PARASITES 333 

and is characterized by a localized or general indurated or " hide- 
bound" condition of the skin. 

Lesions. — (a) In the circumscribed form, hard and inelastic 
patches, varying in size, and of a waxy or dead-white appearance, 
are found on the skin, (b) In the diffuse form, which usually occurs 
on the face or extremities, a diffuse, brawny induration gradually 
develops. The skin becomes firm, hard, and so closely united to the 
subcutaneous tissue that it cannot be picked up or pinched. It is com- 
monly glossy, drier than normal, and unusually smooth. The color 
may be natural. 

Smallpox is an acute infectious febrile disease, distinguished by 
a peculiar odor and a characteristic eruption which is at first papular, 
then becomes vesicular, and finally pustulate. It is seen most often 
among the improperly vaccinated in over-crowded districts during fall 
and winter. Councilman has announced ( 1903) the presence of a pro- 
tozoon * in the skin lesion at the papular stage of the disease, thus con- 
firming the work of Guarnieri with the Cytorrhyctes variola. This 
discovery has been confirmed by Calkins (1904) and others, but is 
not yet fully accepted. Streptococci are always found in the pustules, 
and this infection may be severe. Stokes 2 thinks that the primary 
infection in smallpox takes place in the lungs, probably by inhalation. 
The serious and fatal lesions are, however, usually due to secondary 
infection by the Streptococcus pyogenes from the skin and respiratory 
tract, and to this are due the visceral changes, such as thrombosis, 
local necrosis, and the various pulmonary lesions. The physician 
should always vaccinate himself both before and after making ah 
autopsy on a smallpox case. Frazer 3 reports a case of oyster poisoning 
which closely simulated smallpox in its rash and its general symptoms. 
During the Civil War croton oil was at times rubbed on the skin to 
produce a rash simulating smallpox. 

Lesions. — (A) The skin is the seat of a rash which appears first 
on the forehead and wrists as shot-like papules, progressing to umbili- 
cated vesicles, pustules, and crusts. The epidermis of the hands and 

1 See Ziegler's General Pathology, translation by Cattell, 1895, p. 39: "It is 
not impossible that other infectious diseases — for instance, smallpox — are caused by- 
parasites that belong among the protozoa." Councilman's latest paper on this 
subject is to be found in Amer. Med., October 21, 1905. 

2 Johns Hopkins Bull, August, 1903. 

3 Medical Record, September 2, 1902. 



334 POST-MORTEM EXAMINATIONS 

feet may be shed entire. The skin may be plum-colored, and the face 
swollen. (B) On the mucous membranes from the mouth to the 
rectum the rash may also be found, but on account of the moisture the 
pocks are not quite so characteristic in these situations as upon the 
skin. (C) The larynx, trachea, and bronchi show in some cases 
deep ulcerations. In the larynx a fibrinous exudate is almost always 
found, and at times cedema; and necrosis of the cartilages may follow. 
(D) Swelling of the Peyer's patches is not uncommon. (E) The 
vagina may show the eruption. The spleen as a rule is markedly 
enlarged, but it may be small, very dark, and firm. (F) The liver 
shows evidence of parenchymatous inflammation and fatty degenera- 
tion, and there may be small areas of necrosis. (G) The heart is 
flabby and pale. The myocardium shows cloudy swelling and fatty 
degeneration ; it is often dark brown in color, and may be firm to the 
touch. The cavities contain little or no clotted blood, and the arterial 
trunks are nearly empty. (H) Kidney lesions are not common. 
There may be cloudy swelling and areas of focal necrosis. The pelvis 
may be blocked with dark clots which sometimes extend into the 
ureters. (/) In pregnant women abortion almost invariably occurs. 
In some cases the foetus shows evidence of the disease, in others none ; 
and cases have been reported where the foetus had lesions while the 
mother had no evidence of illness. 1 (/) In black smallpox, the 
hemorrhagic form of the disease, there may be found hemorrhages on 
all the mucous and serous membranes, and in the joints, the paren- 
chyma of organs, the connective tissue and nerve-sheaths, and some- 
times in the bone-marrow and muscles. Death in such cases may take 
place quickly. 

Complications. — (a) True nephritis is rare, but albuminuria is 
frequent, (b) The arteries, bones, conjunctiva, and middle ear 
commonly show purulent changes, (c) Myocarditis, endocarditis, and 
pericarditis are comparatively common. 

Sprue (Psilosis) is a chronic remittent thrush-like inflammation 
of the whole or a part of the mucous membrane of the alimentary 
canal, associated with suppression of or interference with the glandu- 
lar functions of the organs of digestion. It occurs principally in 
persons residing, or who have resided, in tropical or subtropical 
climates. Apparently nothing is known of its origin. In most cases 
reported rigor mortis was absent, or appeared late. 



1 La Riforma Medica, March 14, 1902. 



DISEASES DUE TO PARASITES 335 

Lesions. — (A) The thoracic organs, the abdominal viscera, 
and the tissues generally are found to be much wasted, giving the body 
a mummified appearance. (B) Ancemia is always marked. (C) 
The mucous membrane of the tongue, mouth, and oesophagus is 
bare, inflamed, and eroded. (D) The bowel is exceedingly thin, and 
on opening it a thick layer of dirty-gray viscid and tenacious mucus 
is seen. The villi and glands are eroded, missing, or may be dilated 
and filled with mucous material. On removing this mucus, areas of 
congestion, ulceration, pigmentation, or thickening may be found. 
The mesenteric glands are generally enlarged. 

Syphilis is a chronic contagious disease, due to the Treponema 
pallidum {Spirochceta pallida), and acquired by direct inoculation, 
or by inheritance. Lustgarten (1884) and van Niessen have each 
described organisms, the former having probably found the smegma 
bacillus. Schiiller defends a former announcement * of the discovery 
of a protozoon-like parasite in syphilis. Schaudinn and Hoffmann 2 
describe a spiroehseta present in syphilitic lesions, and in the blood, 
which Metschnikoff has confirmed by discovering it in experimental 
syphilis of the ape. In this country, presence of an organism has been 
confirmed by many investigators. It has been found in the urine of 
a patient with active secondary manifestations and in the liver of 
a new-born syphilitic babe. 

Lesions. — I. Acquired form. — (a) Primary stage. (1) The hard 
or Hunterian chancre is the initial lesion, beginning at the site of 
inoculation as a small red papule, usually situated at the junction of 
the skin and mucous membrane. It gradually enlarges and breaks in 
the centre, leaving a small ulcer with indurated edges and base. Micro- 
scopically the field consists of the usual signs of chronic inflammatory 
tissue, — epithelioid cells, giant-cells, cellular infiltration of the con- 
nective tissue, filling of the lymph spaces with round cells, etc. Chancre 
may, though rarely, appear on different parts of the body at the same 
time, when it is known as chancre a distance. Anthony 3 has observed 
a patient who had a chancre of the penis, of the tongue, and of the 



1 Centralblatt f. Bakteriologie, 1902, vol. xxvii, nos. 5-9. 

2 Deut. med. Wchnschr., 1905, vol. xxxi, no. 18. This protozoon is called by 
Vullemin of the genus Spironema and by Stiles and Pfender Micro spironema. 
There is an excellent illustration of this organism in the iV. Y. Med. Jr., March 
24, 1906. 

3 Jr. Amer. Med. Assoc., June 6, 1903. 



33 5 POST-MORTEM EXAMINATIONS 

finger at the same time. The chancre runs a self-limited course and 
heals, leaving a scar which may be found post mortem. That syphilis 
may be cured is shown by undoubted cases of second infection. The 
soft chancre (ulcus molle) is due to a bacillus described by Ducrey in 
1889, Zomasczewski 1 having performed on his own person the neces- 
sary inoculation for experimental effect on the tongue. This organism 
resembles that of plague, and does not give rise to systemic infection. 
(2) Lymphatic enlargement, especially of the glands of the groin, 
neck, and elbow, follows the primary inoculation. When chancre a 
distance occurs, only the glands in connection with one of the lesions 
are enlarged. 

(b) Secondary stage. (1) A reddish-brown or copper-colored 
cutaneous rash occurs in about 30 days. It is polymorphous, varying 
in form from an erythema to a pustular eruption, and is symmetrically 
distributed, appearing most frequently on the chest, abdomen, and 
flexor surfaces of the arms. (2) The mucous patch is a softened and 
macerated, slightly elevated area of epithelium on the mucous mem- 
branes or on the moist regions of the skin; it is most frequently seen 
in the mouth, the throat, and about the anus. It is of irregular shape, 
and does not discharge pus. (3) The hair of the scalp is decidedly 
thin. (4) On the tonsils and larynx ulcers may occur. In the 
larynx there is erythema; on the cords or ventricular bands occur 
symmetrical, recess-like, whitish ulcers, superficial or deep, with raised 
edges, (5) About the vulva and anus warts may be found. (6) 
Iritis, choroiditis, and keratitis are common. Retinitis is rare. (7) 
The finger-nails may be diseased, forming dry or moist onychia. 
Dactylitis is common. (8) Both the bone and the periosteum may 
be affected, causing hyperostosis, usually of the tibia, skull, hard 
palate, and ulna ; or they may manifest themselves as inflammatory 
changes in the medulla, with marked tendency to the formation of 
new bone. (9) In the joints there may be serous or serofibrinous 
inflammation, with thickened capsules, proliferation of synovial 
fringes, and fibrillation and erosion of the cartilages. 

(c) Tertiary stage. (1) Cutaneous affections are less symmet- 
rical, and show a tendency to ulcerate and destroy the deeper layers of 
the skin, leaving scars. Rupia may develop. (2) The gumma is the 
characteristic lesion, and consists of a cheesy node surrounded by 



Zeitschr. f. Hyg., 1903, vol. xlii. 



DISEASES DUE TO PARASITES 



337 



connective tissue or smaller mass of proliferating- epithelial cells, 
which tend to undergo coagulation necrosis at the centre, (a) Hard 
gummata develop in the internal organs and mucous membranes. They 
most frequently terminate in cicatrization, forming stellate scars which 
often cause marked deformities. (/?) Soft gummata are found in 
bone, skin, etc. They tend to break down and ulcerate, leaving chronic 
indolent sores, often serpiginous. Prolonged suppuration leads to 
amyloid degeneration of organs. This is especially true as a result of 
rectal syphilis in women. 

The above changes, as well as general, but irregularly situated 
fibroid patches of degeneration, are to be looked for post mortem in the 
various organs and tissues, as follows : — 

(a) Syphilis of the Central Nervous System. — (i) Gummata are 
usually multiple, varying in size from a pea to a walnut. In the cere- 
brum they occur along the sulci. They appear also in the meninges, 
associated with thickening of these membranes. Heubner describes two 
forms: (a) grayish or grayish-red in color; on section moist, and 
exuding a small amount of juice; (/?) quite hard and dry, with dis- 
tinct outline; on section cheesy, and looking not unlike tubercular 
growths; they may undergo cystic degeneration. (2) Gummatous 
arteritis and sclerosis of both arteries and nerve-tissue may exist. (3) 
There may be softening due to obstruction of the vessels from pres- 
sure or from endarteritis. (4) Tabes dor sails and dementia para- 
lytica are late (parasyphilitis manifestations of degeneration of nerve- 
tissue. At Philadelphia, in 1898, a man was condemned to death for 
killing a person in cold blood. A commission of experts pronounced 
him sane. The man committed suicide by hanging, and I found at the 
postmortem numerous gummata of the brain, situated especially in 
the right temporal and frontal regions. 

(b) Syphilis of the Circulatory System. — (1) Gummata are rare. 
(2) Fibrosis of the heart-muscle is common, and amyloid degen- 
eration has been noted. Sclerosis of the valves (especially the aortic 
valve) and warty endocarditis are common. (3) Arteriosclerosis, 
atheroma, aneurism, and endarteritis obliterans occur frequently. 

(c) Syphilis of the G astro-intestinal Tract. — The lesions in this 
situation may be chancre, ulcers, localized fibrous patches, gummata, 
or miliary nodules. (1) There is a sclerous glossitis or leucoplasia 
present, which by some is supposed to be characteristic of syphilis. 
(2) The oesophagus is rarely affected. Ulceration or stenosis may be 

22 



338 POST-MORTEM EXAMINATIONS 

present. (3) The pharynx may be the seat of ulcers, phlegmonous 
inflammations, or abscesses. (4) The small intestine and the 
caecum often show ulcerations. ( 5 ) The rectum is not infrequently 
the seat of cicatricial contraction, most commonly seen in women. 
Mucous patches or condylomatous masses may be seen about the anus. 

(d) Syphilis of the Kidneys. — (1) Gummata are not infrequent. 
(2) Acute nephritis may occur, but chronic interstitial nephritis is 
more common. This is localized and is caused by overgrowth of fibrous 
tissue, the shrinking of which results in marked irregularity of the 
surface of the kidney. It is sometimes hard to distinguish it from 
old infarcts, but the color, which in syphilis is gray and in infarcts is 
brown, is a rather good point of differentiation. 

(e) Syphilis of the Liver. — (1) Gummata may be small pale- 
grayish nodules, or larger nodules yellowish in color. Usually they 
are multiple (miliary). Although they may be present in any part 
of the organ, the most common situation is at the junction of the right 
and left lobes. Great deformity results from healing and contraction. 
(2) In diffuse syphilitic hepatitis there is a marked fibrous change, the 
organ being hard, firm, and resistant, and divisible into twenty or more 
lobules. The disease usually begins with perihepatitis, which frequently 
causes adhesions to> the surrounding structures. With contraction of 
the fibrous tissue, great deformities of the liver become manifest. Capil- 
lary bile ducts may be present in abundance in the cirrhosed portion. 

(/) Syphilis of the Testis. — (1) Gummatous growths usually 
involve the epididymis, which becomes a hard mass, from the size 
of a bean to that of a walnut. It affects the head of the epididymis more 
commonly than the body. (2) In interstitial orchitis the progress of 
the disease is slow. The testis is larger than when normal, and is 
distinctly harder to the touch. The overlying skin is not adherent, 
and there is no tendency to suppuration. 

(g) Syphilis of the Respiratory Tract. — (1) Gummata may appear 
towards the base of the epiglottis. These break down, producing 
deep flask-shaped ulcerations, which may heal by connective tissue 
that shrinks and produces stenosis. Islands of connective tissue com- 
monly appear between the cicatrices, and form inflammatory excres- 
cences. The neighboring cartilages may show symmetrical necrotic 
changes. Diffuse infiltration of mucous membranes may occur. A 
fatal termination may result, due to perforation of an artery. (2) 
The bronchi may be stenosed or obliterated. (3) In the lungs, 



DISEASES DUE TO PARASITES 339 

gummata may vary in size from a pea to a goose's egg; they are 
usually limited to one lung, and generally to the middle portion, near 
the hilum. They are grayish-yellow in color, and are embedded in 
connective tissue. They may dry up and calcify. The parts around 
them are hard and brawny, and of a glossy lustre. There may be a 
fibrinous interstitial pneumonia, usually bilateral and diffuse, in which 
the lesions are hard, large, and pale or dark grayish-red in color. The 
middle of the right lung or the apex of either lung is the part most 
frequently involved. The pleura is thickened and adherent. Some of 
the cases described as being of syphilitic origin are nothing more or 
less than a chronic interstitial tuberculous pneumonia. 

(h) Syphilis of Bone. — Gummata appear; they are usually 
periosteal but may be medullary. If peripherally situated, they are 
often multiple and of varying size. The affected area may be dense 
and brimstone-colored, or necrotic with a fat gummy mass. Recent 
periosteal gummata are flat swellings of elastic consistence, and on sec- 
tion have a gelatinous texture. They are always accompanied by 
resorption of bone. Osteomyelitic gummata occur frequently in the 
phalanges (dactylitis), and in the diploe of the skull. They form foci 
that are gelatinous or fibrogelatinous and dirty-yellow in color, or puri- 
form. They may cause well-marked caries and necrosis, which in 
the skull sometimes lead to perforation, and in other cases to caseous 
and fibroid changes, not only in tissues surrounding the gummata 
but also in the tumor itself. Ancemia is marked, and the skin looks 
muddy. Parotitis may occur. 

II. Congenital form. — (a) The primary stage is not seen, (b) 
Secondary stage. At birth the infant may be apparently healthy. It 
may develop no symptoms for several weeks or months, or well- 
marked lesions may be noted at once. ( 1 ) The wasted and aged 
appearance is conspicuous, and as the child grows, assymmetry and poor 
development are noted, especially in the teeth, which are wedge- 
shaped and the cutting edge notched (Hutchinson's teeth). (2) Pem- 
phigus may occur on hands and feet. ( 3 ) The lips may be ulcerated, 
and the mouth and anus fissured. (4) Inflammation of the mucous 
membrane of the nose, with papillary infiltration, is present, and necro- 
sis of bone, resulting in the broken-nose deformity, may occur. 
Goundou, a rare tropical affection of the negro race, which is charac- 
terized by tumors of the nasal bones, is supposed by some writers to be 
a congenital syphilitic osteitis. (5) Lesions of the joints are rare. 



340 POST-MORTEM EXAMINATIONS 

(6) The spleen and liver are enlarged, and may be the seat of 
parenchymatous rather than gummatous infiltrations. (7) Lesions 
of the lungs, (a) White pneumonia, in which the affected lung is 
heavy and airless, presenting on section a grayish-white appearance. 
The lungs are distended and bear the imprint of the ribs; they are 
dense, friable, smooth, and opaque. (/?) Miliary gummata, which are 
small in size, grayish in color and firm in texture, and are more or less 
symmetrically distributed through the lungs. (8) Acute iritis is not 
infrequent. (9) When dentition occurs, the teeth are wedge-shaped, 
and the cutting edges notched (Hutchinson's teeth). (10) Lesions 
of the bones, (a) In the skull, craniotabes (wasting at the sites of 
decubitus) is common in very young children. Incrustations known 
as " Parrot's nodes" are seen about the anterior fontanelle. (/?) 
Long bones, the tibia, fibula, and radius, usually show charac- 
teristic changes, and the epiphyses may be separated and enlarged. 
Parrot's nodes occur also in the tibia and the humerus. When the 
tibia is affected, it often grows more rapidly than the fibula, thus 
throwing the foot into the position of valgus. The total length of the 
limbs may be increased. The bones may become brittle from caries, 
or very heavy from eburnation. Later, about the sixth year, the 
tibia may become the seat of a chronic gummatous periostitis, leading 
to great thickening of the bones, and often to swellings, forming the 
sabre-blade deformity. Disfiguring scars always remain. (7) Dacty- 
litis is not uncommon. The process may be localized to the border zone 
between epiphysis and diaphysis; this zone has a ragged edge and a 
yellowish color, and becomes hard like mortar, (c) The tertiary 
stage in the congenital form is marked by noticeably fewer lesions than 
in the acquired form. (1) The chief lesion of the eye is an inter- 
stitial keratitis affecting both eyes, which usually does not appear until 
near adolescence or adult life. (2) If the ear be affected, deafness, 
of labyrinthine origin, often occurs. 

Tetanus is an infectious disease due to the Bacillus tetani, and 
is characterized by tonic convulsions with clonic exacerbations. The 
bacilli multiply at the site of the wound, which is usually of a pene- 
trating character, and do not invade the blood or organs, except very 
late in the course of the disease. The toxin acts destructively, especially 
on the nervous system. Four hundred and fifteen cases of Fourth of 
July tetanus are reported as occurring in 1903. 1 The mortality was 

1 Jr. Amcr. Med. Assoc, August 29, 1903. 



DISEASES DUE TO PARASITES 



341 



about ninety-five per cent. As a result of recent investigations Dr. 
David H. Dolley 1 concludes : " There is abundant evidence from clini- 
cal observations and animal experiments that the wads of certain 
blank cartridges contain the Bacillus tetani" A number of cases 
of tetanus following vaccination were reported in 1903, the virus in one 
instance having been prepared by a Board of Health. 

Finlay found the bacillus abundant in the wick used for tying the 
umbilical cord, an explanation of the etiology of tetanus neonatorum. 

Lesions, of which none is characteristic, are : {A) The condition of 
the wound depends upon the kind and extent of the injury. In 
tetanus neonatorum the umbilicus may be the original seat of inocula- 
tion and be inflamed. (B) The central nervous system shows 
intense congestion, with perivascular exudations and granular changes 
in the nerve-cells. Some investigators have found swellings and areas 
of disintegration in the gray matter of the cord, with exudation of a 
finely granular material and of disintegrated blood. The spinal 
ganglia should always be saved for microscopic study. (C) The 
rectus muscle has been found ruptured as the result of a spasm. 
(D) He art- failure or asphyxia may cause death. 

Thrush is a disease due to the O'idium albicans or thrush fungus, 
which shows many variations upon cultivation, and is closely allied to 
Blastomycetes. Thrush is most commonly seen in children ; in adults, 
in those who have died of chronic tuberculosis, diabetes, and other 
cachexias. 

Lesions. — {A) The mouth, tongue, cheeks, etc., are more or 
less densely covered with minute slightly raised white spots, which 
are quite firm and adherent to the mucous membrane, but which may 
be scraped off, leaving the mucosa intact. Microscopic examination 
of the scrapings shows the characteristic fungus. (B) The oesopha- 
gus is occasionally invaded, the fungus growing to such an extent as 
seriously to obstruct its lumen. (C) The stomach and caecum are 
at times affected. (D) Systemic infection may occur, and the organ- 
isms may grow into blood-vessels. 

Tuberculosis is an infectious disease incited by the tubercle 
bacillus, discovered by Koch 2 in 1882, and is characterized by an 
exudative and productive inflammation in which the typical morpho- 
logic feature in reacting to this irritant consists in the formation 

1 Jr. Aincr. Med. Assoc, February 11, 1904. 
"Bert. klin. Wchnschr., April 10, 1882. 



3 42 POST-MORTEM EXAMINATIONS 

of small nodular bodies called tubercles, which later conglomerate 
and undergo cheesy degeneration. The tubercle of Laennec when 
first formed is a grayish and translucent spheroidal body, in size from 
a microscopic object to that of a pea. It is composed of a collection 
of leucocytes attracted to the spot by the positive chemotactic action 
of the bacilli, of larger (so-called epithelioid) cells, and of a few giant- 
cells. It is a non-vascular formation, showing little tendency to form 
new blood-vessels. By the fusion and extension of many such miliary 
tubercles, larger nodules are formed. As the toxic products of 
bacterial growth accumulate, this new-formed tissue, as well as the 
old tissue of the infected area, undergoes coagulation necrosis, the 
process appearing first in the centre and extending outwards until 
the entire nodule is converted into an opaque granular or structure- 
less mass. Fatty degeneration accompanies the necrosis, and the 
process is called caseation. Such a cheesy mass may soften and 
thus form the so-called cold abscess, the contents of which consist 
mainly of broken-down tuberculous tissue, fatty debris, and water; 
there is no definite limiting membrane. The contents of such an 
abscess are usually sterile, though supposed by von Schron to be 
made up largely of the phthisiogenic organism described by him. 
If secondary infection of the mass by pyogenic organisms occurs, 
suppuration and the formation of a true abscess results. In this 
case a true inflammatory limiting membrane will form as a result 
of reaction to the pyogenic infection, or calcification of the mass 
may take place, with arrest of the process. Instead of caseation, 
a secondary inflammatory reaction may take place in tissue surround- 
ing the area affected, which is thus encapsulated, and then by gradual 
pressure and absorption is removed and replaced by a hard fibrous 
scar. When the affected area is small, the blood-supply is good, 
and the patient is under favorable conditions, resolution may occur. 
It is estimated by careful observers that seventy-five per cent, or more 
of all persons who die after the age of forty years in places where tuber- 
culosis is prevalent show some form of previous tuberculosis in their 
lungs, pulmonary glands, or elsewhere in the body. 

Koch's assertions, made before the International Congress on 
Tuberculosis at London in 1901, that human tuberculosis differs from 
bovine and cannot be transmitted to cattle, and that man does not, 
except in the rarest instances, contract tuberculosis from the cow, 
have been vigorously combated by the British Royal Commission 



DISEASES DUE TO PARASITES 343 

and by many independent workers. Even Kossel, of Germany, 
announced, as the result of his special investigation, supposed to have 
been undertaken at the suggestion of Koch himself, at the Inter- 
national Congress on Tuberculosis, held in Paris, October 2-7, 1905, 
that (1) bacteriological examination of the tuberculous lesions of 
man, cattle, and swine enables us to distinguish two types of tubercle 
bacillus, which may be provisionally designated as " human" and 
" bovine." (2) Bovine tuberculosis, so wide-spread, is exclusively 
due to infection by the bacillus of the bovine type. 1 (3) Swine are 
susceptible in high degree to bacilli of the bovine type; to a less 
degree to bacilli of the human type. (4) Tuberculosis in man 
is due chiefly to infection by the tubercle bacillus of the human 
type, which is transmissible from man to man. (5) Tuberculous 
lesions may be produced in man by the tubercle bacillus of the 
bovine type. (6) The transmission of tubercle bacilli of bovine 
type to man may occur through food products derived from tuber- 
culous animals, chiefly through the milk of cows with tuberculo- 
sis of the udder. (7) The role played by infection from animal 
sources in the spread of human tuberculosis is small compared 
with the danger from phthisical persons. These investigations 
sustain the stand taken by Mazyck P. Ravenel in London in 1901, 
and have confirmed Theobald Smith's work done in 1898. At 
the 1905 Congress, von Behring made an important announcement 
of a new cure for tuberculosis, which is based upon a cellular, and 
not upon a humoral or antitoxic, immunity. He derives a substance 
from the tubercle bacilli, tentatively termed TC, which when modified 
by cellular activity, is spoken of as TX. That cattle may be immun- 
ized against tuberculosis seems to be a settled fact, and von Behring 
believes that TC when freed from other substances exercises a specific 
action on the cells, especially on those of a lymphoid nature. Now, 
if this TC could be supplied to the organism, and the work of pre- 
paring it thus be saved, a passive immunization would be secured in 
place of an active one. Experiment evidence leads him to believe 
that three groups of substances derived from the tubercle bacillus may 
be distinguished: (1) A fermentative, catalytic substance, soluble 
in water, which is called TV, and represents the toxic factor of 

1 The writer has been struck with the freedom from endemic tuberculosis in 
those districts of Switzerland and of this country in which fresh cow's milk is 
not used. See Lancet, May 26, 1906, for Koch's Nobel lecture upon tuberculosis. 



344 POST-MORTEM EXAMINATIONS 

Koch's tuberculin ; a gramme in the dried state being more powerfully 
toxic than a whole litre of Koch's tuberculin. (2) A globulin, called 
TGL, which is soluble in a ten per cent, solution of sodium chlorid. 
This is also toxic. (3) There are a number of non-toxic substances, 
which are soluble in such agents as alcohol, ether, and chloroform. If 
the bacillus be deprived of these groups of bodies it may retain its 
shape and still stain as does the tubercle bacillus. It is this " rest 
bacillus" from which von Behring, by a secret process, though prom- 
ising to supply the preparation to laboratory workers, obtains a sub- 
stance that is capable of absorption by the lymphoid cells of certain 
of the experimental animals. TC is capable of producing the tubercles, 
and if one reads the later articles by von Schron it will be seen that 
this writer believes that the tubercle bacillus itself is the agent 
which produces the tubercle, while it is the phthisiogenic organism 
which causes the caseation and subsequent softening. 

Lesions. — I. Respiratory Tract. (A) Larynx. The lesions may 
be primary or secondary, usually the latter, and may manifest them- 
selves as either miliary or ulcerative tuberculosis. In early cases the 
epithelium is intact, the tubercle starting in the mucosa or the sub- 
mucosa, which are pale and thick. The arytenoids are swollen, 
and small shallow ulcers with pale eroded bases and irregular walls 
eventually develop in the arytenoid space. Necrosis of the cartilage 
rings is not uncommon. 

(B) Lungs, (a) Acute infection. (1) In acute miliary 
tuberculosis the lesions are usually present in both lungs. They are 
frequently so small and transparent that they may be overlooked on 
macroscopic examination; they are more numerous on the pleural 
surface, and are often as readily felt as seen. At other times they 
are aggregated in localized spots, or may even become diffuse. In 
the latter case the lung is increased in size and weight; is firm in 
consistency; assumes a darker shade of red; and crepitates. The 
pulmonary vessels having been opened with scissors, miliary tubercles 
are often seen in the veins, but seldom in the arteries, even though 
the infection has been brought about through the circulation. Such 
tubercles may, however, be localized near an old caseous mass, the 
lymphatic system then being the transmitter. Local spots of emphy- 
sema are seen if the condition is not very acute. The tubercles may 
be peribronchial, perivascular, or in the parenchyma. There is a 
chronic miliary tuberculosis which presents a combination of lesions 



DISEASES DUE TO PARASITES 345 

of both acute miliary tuberculosis and phthisis, and is the connecting 
link between the two. The bronchial glands are usually enlarged 
and caseous. (2) Phthisis florida {acute phthisis) may show itself 
as bronchopneumonic tubercles, lobar pneumonic tubercles, or a com- 
bination of both. In children the central portion of the lung is 
peculiarly apt to be affected. The formation of consolidation and 
cavities presents a varied appearance. One lobe only, or more or 
less of the whole lung, may be affected. The organ is heavy; the 
implicated portions do not collapse, and are firm and airless. The 
pleura is covered with a thin exudate. On section the condition may 
resemble red or gray hepatization or an irregular intermediate stage 
between the two. In other instances the lung presents a mottled 
appearance, some areas being intensely congested, others exhibiting 
a characteristic pale-gray gelatinous exudate; others still, caseous 
degeneration and, not infrequently, cavity formation. The lung may 
be honey-combed with innumerable small cavities. Softening some- 
times occurs immediately below the pleura, leading to necrosis and 
pneumothorax. Areas of pulmonary tissue affected with croupous 
pneumonia, from which the patient may have succumbed, are often 
seen. Such lungs readily caseate and produce ulcerative excavations 
of considerable size, (b) Chronic infection. (1) In ulcerative tuber- 
culosis the apex is involved (according to Kidd) five hundred times 
to one involvement of the base. The lesions are varied. There 
may be caseous nodules, which are grayish, white, or yellow in color; 
cavities may exist, which, in more acute cases, have walls made up 
of soft caseous masses; or, in the more chronic cases, these walls are 
replaced by pyogenic membranes of greater or less density, and at 
times are covered with granulations. They are dry or more or less 
purulent. Frequently trabecular are seen in the walls; these are the 
blood-vessels, branches of the pulmonary artery, which have resisted 
the tuberculous process. The arteries sometimes become aneurismal, 
and their rupture may be followed by hemorrhage severe enough to 
cause death. Frequently they are contracted and empty, due to a 
previous endarteritis or thrombosis. Pneumonic areas and evidences 
of chronic bronchitis and fibrosis are seen; the bronchi may be 
thickened, the lumina of the smaller ones being obliterated and the 
larger tubes showing caseous deposits in the submucous and fibrous 
coats. Some thickening of the pleura is constant. This may be 
merely an acutely inflamed spot rubbing against a corresponding area 



34 5 POST-MORTEM EXAMINATIONS 

on the parietal pleura, or it may be tightly adherent to it. Not 
infrequently perforation causes a pyopneumothorax. Enlarged bron- 
chial glands, which are caseous and often pigmented, are found. (2) 
In fibroid phthisis the organ is permeated with interstitial overgrowth, 
which may appear independently as dense pigmented strands in the 
apices, with cretaceous nodules or dry caseous material in the centre, 
the interstitial change being most prominent in some cases, and the 
tuberculous process being slightly more marked in others. The 
unaffected portions of the lung are largely emphysematous, and 
pigmentation is considerable. 

II. Alimentary Tract. The disease may be primary in the 
mucous membranes, as from the eating of infected food, or secondary, 
as from disease of the lungs, or, rarely, through extension from the 
peritoneum. (A) Mouth, (a) Primary tuberculosis is usually 
miliary. The tonsils and uvula are more often thus affected than 
was formerly supposed. There may be ulceration, or a miliary infil- 
tration usually associated with hypertrophy, (b) Secondary tuber- 
culosis, consequent upon tuberculosis of the face, larynx, or lungs, 
attacks the tongue, lips, or cheeks, or the hard and soft palate. It 
may be miliary or caseous. The salivary glands are very rarely 
affected, but the pharynx is often covered with an eruption of miliary 
granules. 

(B) (Esophagus, (a) Primary tuberculosis is very rare. 
(b) Secondary tuberculosis, through extension from the lungs or 
larynx, is comparatively common. The lesions may be miliary, case- 
ous, or ulcerative. 

(C) Stomach. This is rarely the seat of the disease. I have 
had one case of primary gastric tuberculosis in a young child. When it 
occurs it may lead to perforation of this viscus. 

(D) Intestines. The lesions occur in the ileum, colon, 
rectum, and anus. The most frequent seat of the disease is the 
ileum just above the ileocecal valve, as it is here that a stasis of the 
intestinal contents occurs and a favorable opportunity is given for 
the growth of the tubercle bacillus. Small, firm, gray nodules develop, 
which soon soften and become yellow in the centre, generally starting 
in a solitary and agminated gland. If cut into at this stage, pus does 
not exude as in an ordinary abscess, but a thick caseous material may 
be pressed out. The mucous membrane finally breaks down, and the 
cheesy material is erupted. There remains an irregular ulcer with a 



DISEASES DUE TO PARASITES 



347 



swollen cheesy base, having hard yellow spots and thickened edges 
(the primary tuberculous ulcer of Rokitansky), which soon com- 
bines with others and enlarges irregularly (the secondary tuberculous 
ulcer of Rokitansky). Miliary tubercles in the form of small gray 
nodules now appear at the base and edges of the ulcer and in its immedi- 
ate vicinity. The longer axis of the ulcer is usually at right angles 
to the intestine, and it may extend around the bowel. 1 Hemorrhages 
may occur, particularly at the edges. The submucosa and muscularis 
are usually involved, and colonies of young tubercles may be scat- 
tered over the serous membrane. Perforation is rare, though gan- 
grene may occur in a very rapidly developing ulcer. Healing some- 
times takes place, and there may be solitary or multiple areas of 
cicatricial tissue. Stenosis of the bowel may occur. Pericecal 
abscess and appendicitis may be tuberculous in origin. Fistula in ano 
is quite common, and hemorrhoids are a frequent complication. 

III. Liver. The liver is always involved in general tuber- 
culosis. It is pale in color, often fatty, and presents miliary tubercles 
or caseous masses which may break down into numerous small 
abscesses, especially about the smaller bile ducts. There may be slight 
increase in the connective tissues, leading to tubercular cirrhosis. 

IV. Spleen, (a) In acute infection the organ is increased in 
size, firm in consistency, deeply congested, and on section presents a 
greater or less number of symmetrically distributed, small, grayish, 
semi-translucent bodies, slightly raised above the surface and firmly 
adherent. This condition is seldom a primary lesion, but is common 
as a secondary infection, (b) In the chronic form caseous tuber- 
culosis is attended by a variable number of irregularly distributed 
cheesy nodules or diffuse areas of caseation. These may be as small 
as a pea or as large as a walnut or larger. They not infrequently 
break down and form abscesses through pyogenic infection, (c) 
Tuberculous perisplenitis frequently occurs as an extension from 
peritonitis. 

V. The genito-urinary system is most often affected in males 
from twenty to forty years of age. 

(A) Kidneys, (a) Acute miliary infection is not infrequent, 
and may be primary or secondary. The disease is most marked in 
the cortex. It may be limited to the areas which are supplied by a 

1 See Table of Differences between Typhoid and Tuberculous Ulcers, p. 354. 



348 POST-MORTEM EXAMINATIONS 

single blood-vessel. The miliary tubercles may be seen in a row in 
the direction of the vasa interlobularia. Necrosis and caseation 
rapidly follow. One or both organs may be affected, but at autopsy 
both are found to be enlarged, (b) In the chronic form, not infre- 
quently one kidney may be completely destroyed and converted into 
a series of cysts, which contain a cheesy substance ; lime salts may be 
deposited in their walls. This form of the disease frequently starts 
at the apices of the pyramids. The walls of the pelvis may be thick- 
ened and cheesy, and the mucous membrane may be converted into 
a necrotic ulcerating mass. The ureters may be thickened, caseous, 
or ulcerated. 

(B) Bladder. The infection is nearly always secondary, par- 
ticularly to tuberculosis in the pelvis of the kidney. The bladder is 
small, shrunken, thickened, and surrounded by sclerosed tissue. 
Lenticular ulcers, surrounded by a zone of inflammation, are com- 
monly found situated at the trigone or the fundus. The ureters are 
also involved, being dilated and ulcerated. The involvement of the 
ureters, as of the prostate and the vesicul^e seminales, is rarely 
primary. To find tubercle bacilli in the urine, repeated centrifugation 
with a 5 per cent, sodium hydrate solution should be employed, the 
precipitate being stained in the usual manner for showing these 
organisms. Care must be taken not to get the smegma bacillus ; it is 
therefore advisable that the urine be collected with the strictest 
precautions. 

(C) Testes. Infection may occur before the second year. It 
may be secondary to peritoneal tuberculosis. At times the greater 
part of the testis is destroyed, its stroma being replaced by a softened 
or still firm caseous deposit. It may be associated with syphilis. 

(D) Ovaries, Fallopian Tubes, and Uterus. The disease is 
usually bilateral. The tubes are enlarged, the walls are thickened and 
infiltrated, and the contents are cheesy. Adhesion to the neighboring 
organs is always found. The ovary may be affected secondarily, 
and the affection may extend to the uterus and vagina. 

VI. Circulatory System. (A) The heart will show hyper- 
trophy when the lungs are affected, resulting from the increased 
pulmonary resistance. Tubercles may be seen in the endocardium, 
the pericardium, and the myocardium. 

(B) Vessels. Primary tuberculosis of the larger vessels is 
unknown; secondary lesions are not infrequently found if carefully 



DISEASES DUE TO PARASITES 349 

searched for. In the lungs, brain, and other organs the smaller 
arteries are usually involved in an acute infiltration which leads to 
thrombosis. Tubercles may develop in the walls of the vessels, par- 
ticularly in the muscularis, and undergo softening, resulting in 
hemorrhage or in a wide-spread distribution of the tuberculous 
infection. 

VII. Serous Membranes. (A) Peritoneum, (a) Miliary 
form. On opening the abdominal cavity the membrane seems to be 
covered to a greater or less extent with miliary tubercles, which are 
present in the mesentery and the omentum also. Frequently the 
gray nodules follow the distribution of the blood-vessels. The peri- 
toneum does not possess its normal shining surface, but is usually 
pale, somewhat sticky, and lustreless. Often there is little or no 
inflammatory exudate, although petechial hemorrhages are common. 
In many cases there is an effusion of straw-colored or bloody fluid 
which may amount to a litre or more. It contains a considerable 
amount of albumin and some cells. The exudate is rarely purulent. 
(b) Chronic diffuse form. The abdominal viscera and peri- 
toneum are bound together by tough firm membranous bands of 
organized exudate, and the peritoneal cavity is obliterated. The 
exudate is purulent, seropurulent, and at times sacculated. The 
intestinal coils may be shortened and contracted, while the mesen- 
teries and omentum are enormously thickened. The capsules of 
the liver and spleen may undergo extreme thickening, varying from 
a few millimetres to several centimetres. The organs are rough and 
irregular in outline, (c) Ulcerative form. There is a formation 
of caseous masses, which vary in size from a pea to a marble, and 
which tend to run together and break down, forming more or less 
extensive ulcerating surfaces. Adhesions of a serofibrinous or sero- 
purulent character are formed. The new tissues are apt to become 
pigmented and of a gray or almost black color. The intestinal 
walls are very friable. Fistulse, . opening at various points, are not 
infrequent. 

(B) Pleura, (a) The acute form is usually accompanied by 
a serofibrinous effusion, which may become purulent, or it may be 
a proliferative inflammation, leading to thickenings and extensive 
adhesions, (b) The chronic form is characterized by exudation, by 
the formation of cheesy masses, and by a tendency to suppuration. 



350 



POST-MORTEM EXAMINATIONS 



VIII. Bones. Lesions of the bones are very common. The 
tuberculous process starts more frequently in the bone itself than in 
the periosteum, though exceptions occur in the ribs, the vertebrae, 
and the phalanges. In the miliary form, the tubercles are first seen 
in the marrow of the diaphysis. The process starts with a group 
of tubercles surrounded by granulation tissue, a grayish-red zone, 
which may become fibrous and thus limit the process. In this outer 
zone the trabecular become thicker at the expense of the spaces ; while 
in the centre the former are undergoing absorption, the process con- 
stituting rarefying osteitis. Extension takes place by the formation 
of additional tubercles, varying in size from a pea to a hazel-nut, 
containing necrotic trabecular, and tending to run together and to 
shut off the blood-supply. They quickly undergo a cheesy change. 
These areas of caseation may separate as sequestra, which are usually 
small, but sometimes attain the size of a walnut; a whole epiphysis 
(such as the head of the femur) may thus be detached. The trabecu- 
lar of the sequestra are thickened, showing that a chronic inflamma- 
tion was present before the separation occurred. The sequestra may 
be soft and crumbling, or they may be calcified. When the perios- 
teum is first affected, there is rapid enlargement, due to the formation 
of tubercles appearing in spots, or extending over a large area. 
Erosion of the bone follows, and is usually succeeded in turn by an 
abscess, on cutting into which there is found cedematous fibroid tissue 
containing tubercles, granulation tissue with tubercles less typical, 
and a layer chiefly of epithelioid cells, which gradually becomes more 
and more caseous. In the larger long bones the process usually 
begins in the periosteum, at the articular extremity. In the small long 
bones and in the short spongy bones it usually involves all of the 
bone. In the spinal column the deformity known as kyphosis 
results from the softening and collapse of the bodies of the vertebrae. 
The disease occurs most often in the dorsal vertebrae, then in the 
cervical, and less frequently in the lumbar and sacral. Extension 
of the process to the neighboring tissues may cause perforation 
externally, the cold abscesses discharging their softened, cheesy con- 
tents on the back at the side of the spinal column, into the throat, as 
retropharyngeal abscess; at the crest of the ilium; or the so-called 
pus, burrowing by gravity, may form the psoas abscess. 

IX. Joints. Orth describes tuberculous arthritis as follows : 
There is marked doughy and inelastic swelling of the joint and the 



DISEASES DUE TO PARASITES 35 1 

tissue surrounding it. In the periarticular region the tissue has a 
white, pale, smooth, and glistening appearance (tumor albus), and 
it may contain fistulse with granulations on their walls. In the joint 
itself there may be little or no exudate. If present, the exudate is a 
serous or purulent effusion and contains rice-like bodies. The 
synovial membranes are pulpy or gelatinous, and are covered with 
granulations which may be so exuberant as to cover the whole joint 
cavity; they are studded with tubercles. The bone in the neighbor- 
hood may have undergone caries (osteoporosis) and the probe 
can be easily pushed in for considerable distances. Sequestra may 
be found. The cartilage is only secondarily involved. It undergoes 
caries and softening when lifted off by granulations from the synovial 
membrane. Fibrous structures become brawny and fascicular; case- 
ous nodes and cold abscesses are produced, which rupture and form 
fistulous tracts, or sinuses. Tubercle bacilli are present. Tuber- 
culosis may affect a large joint, destroying entirely the cartilage and 
the capsule, and even the head of the bone. The socket is widened, 
the bone in the neighborhood becomes carious and eroded, and disloca- 
tions may occur. This is most common in the hip- joint (coxalgia), 
or in the knee-joint (tumor albus). 

X. Lymphatic Glands. Those most often involved are the 
cervical chain, and the disease extends in the direction opposite to 
that of the lymphatic stream (Treves). The bronchial and mesen- 
teric glands are also frequently affected, the latter constituting 
tabes fite sent eric a. (a) Chronic form. The affected glands are 
hard, with overgrowth of connective tissue, yellowish white in color, 
and non-adherent; they show little tendency to break down and sup- 
purate. The disease seems to be localized, (b) Subacute form. 
The glands are less dense, are grayish white in color, tend to become 
adherent, and to soften and suppurate. There is less connective 
tissue, and tubercle bacilli are more abundant. When tuberculous 
lymphatic glands are associated with phthisis, they are sometimes 
found to have opened into a bronchus and caused the disease. This 
is particularly common in children, and especially when the middle 
and lower lobes are involved. Perforation may also occur into the 
cesophagus, aorta, and pericardium. Generalized adenitis occurs 
rarely. Localized adenitis is often associated with purulent otitis 
media, chronic nasopharyngeal catarrh, eczema of the scalp, con- 
junctivitis, and keratitis. 



35- 



POST-MORTEM EXAMINATIONS 



XL Mammary Gland. The infection occurs usually in women 
of strumous temperament, between the fortieth and sixtieth years, 
and is usually associated with lymphatic enlargement, tuberculosis of 
bone, or other involvement in the neighborhood. The seat of pre- 
dilection is the gland-duct. Induration is at first small, and the 
nodules increase in size very slowly. The nipple may be retracted. 
The skin over the gland becomes riddled with sinuses having indurated 
edges. 

XII. Brain and Cord, (a) Acute miliary tuberculosis. This 
is usually secondary to tuberculosis of the lungs, bronchial glands, 
or bones. The miliary tubercles occur most frequently in the pia 
and arachnoid of the cerebellum, next in the cerebrum, then in 
the pons. They follow the direction of the blood-vessels, and are 
apt to lead to obliteration of the vessels and thus cause necrotic 
softening of the nervous tissue. Serous, seropurulent, or serofibrinous 
exudate is also present. This acute process may result in acute inflam- 
mation of the meninges, principally the pia and arachnoid. It is 
spoken of usually as acute hydrocephalus. This is most pronounced 
towards the base of the brain and occurs most frequently in children. 
I have twice found tubercle bacilli in fluid removed by Quincke's 
lumbar puncture, (b) Chronic me nin go-encephalitis. The mem- 
branes at the base of the brain are most often involved, next in fre- 
quency the optic chiasm, the Sylvian fissure, and the inter- 
peduncular space. The membranes are thickened, firmly adherent, 
and are covered with a fibrinous purulent exudate. The convolutions 
are flattened and the sulci are obliterated. The cerebral substance is 
more or less cedematous. The lateral ventricles are dilated and con- 
tain a turbid fluid, (c) Tuberculous tumors of the brain. Solitary 
tubercles are found most often about the cerebellum. As a rule they 
are attached to the meninges, often to the pia mater. The tubercles 
vary in size from a pea to a small orange. They are grayish yellow 
in color, caseous, and are usually firm and hard, but the centre may 
be semi-fluid. They may be surrounded by submiliary tubercles, but 
are, as a rule, surrounded by a soft translucent tissue. They may 
calcify. Cerebral softening from pressure is not uncommon. 

XIII. Skin, (a) For a description of anatomical zvarts, see 
page 51. (&) Lupus vulgaris is a cutaneous form of tuberculosis, 
the lesion of which begins as a small nodule, reddish brown in color 
and of soft consistence. These nodules vary in size from a pin-head 



DISEASES DUE TO PARASITES 353 

to a cherry, and quickly break down and ulcerate. The ulcers are 
more or less rounded and have a red base covered with granulations. 
The intervening tissues show diffuse infiltration and fibrous hyper- 
plasia. Warty excrescences may develop in the epidermis or in the 
floor of the ulcers. The face is the most common seat of the disease, 
which follows the lymphatic channels. 

Typhoid Fever is an acute infectious disease due to the Bacterium 
typhosum, 1 and is characterized by definite endothelial proliferation 
and subsequent necrosis of the intestinal lymph-follicles (Peyer's 
patches), mesenteric lymph-glands, spleen, bone-marrow, 2 and peri- 
vascular lymph spaces. The organism is found, early in the disease, 
in the intestinal and mesenteric lymph-nodes, and in the spleen, from 
which organ it has been obtained during life by puncture for diagnos- 
tic purposes. Later it may be found in the blood, in typhoid spots, 
in the urine, and in abscesses of the testicles, joints, etc. 

The Widal test and the diazo-reaction may be determined post 
mortem. Ficker 3 recommends the use of fluid containing dead typhoid 
bacilli from a culture of known origin and virulence; these are agglu- 
tinated by the serum from the typhoid case. Ruediger 4 prepares the 
fluid by killing the typhoid cultures with one per cent, formalin 
and adding four cubic centimetres of this to one cubic centimetre 
of the one-to-ten formalized blood under examination. Make a 
control test. 

Lesions. — {A) Intestines. The lesions are most marked in the 
lower ileum, but may exist in the caecum, appendix, and colon; 
rarely in the jejunum, the primary infection rendering secondary 
infection more easy. During the first week there is intense catarrhal 
inflammation of the mucous membrane and some epithelial desqua- 
mation, with moderate or more intense swelling of the lymph-follicles. 
These are red or reddish gray in color and of a rather soft consistency. 
In a mild case, resolution may take place at this stage, and the nodes 
may return to their normal condition. In severe infections, the swelling 
increases and towards the third week softening of the patches with 
ulcerations takes place. 



1 For an account of this organism, see p. 386. 
'Longcope, Phila. Path. Soc, December, 1904. 

* Berl. klin. Wchnschr., November 9, 1903, p. 1021. 

* Journal of Infectious Diseases, 1904, vol. i, p. 236. 

23 



354 



POST-MORTEM EXAMINATIONS 



The differentiation of typhoid and tuberculous ulcers is important, 



and may be tabulated as follows : * — 
Typhoid Ulcers. 

1. Direction often longitudinal, involv- i. 
ing the Peyer's patches, which are 
larger in size, actual amount of sur- 
face affected greater. Extension 
takes place laterally or in depth. 

2. Edges are undermined, ragged, thin, 2. 
vascular, and composed of reddish 
mucosa and submucosa, and this 
fringe may readily be floated out on 
water. 

3. Floor of the ulcer is smooth and 3. 
vascular. 

4. Peritoneal surface opposite the ulcer 4. 
is usually unaltered, but occasionally 

it is inflamed and thickened. Mes- 
entery unaltered; glands enlarged, 
pink, and softened, and hyperplasia 
develops early. 

5. Perforation is more common, both by 5- 
separation of slough and by direct ex- 
tension in depth of the ulcerative 
process. Faeces may escape through 
such a small perforation and peri- 
tonitis result; or hemorrhage may 
follow. Extension takes place either 
laterally or in depth. 

6. Healing is by granulation, the thin 6. 
edges falling on to and uniting with 

the granulating floor of the ulcer. 

7. A smooth cicatrix (often depressed), 7- 
pale, anaemic, or pigmented, and 
covered by a layer of epithelium, but 

no gland-tissue, is left. The ulcer 
seldom breaks out afresh, relapses 
being due to the involvement of ade- 
noid patches previously little damaged. 

8. Typhoid bacilli are found in the 8. 
ulcers. Widal test positive. 

9. Other lesions of typhoid, with the 9. 
clinical history of the case, are to be 
considered. 



Tuberculous Ulcers. 

Direction (frequently) transverse or 
round. This distinction is not so 
characteristic as is sometimes held. 
Extension usually takes place later- 
ally. The ulcers are smaller, and may 
be very numerous. 

Edges are not undermined, but thick, 
prominent, nodulated, terraced, or 
sloping; pale or red; composed of 
tissue infiltrated with tuberculous 
nodules. 

Floor is nodular, irregular, thickened, 
vascular, with pale or yellow points or 
areas, and shows outlying tubercles. 

Peritoneum is thickened; there are 
small yellow or gray points opposite 
the floor of the ulcer, following the 
encircling lines of lymphatics, Mes- 
entery thickened at its attachment to 
the bowel; glands enlarged, firm, and 
gelatinous on section, or caseous. 

Perforation, peritonitis, and hemor- 
rhage are all rare. Extension usually 
takes place laterally. 



Healing is very rare. 



The ulcer leaves a puckered, deeply 
pigmented cicatrix, in which are gray 
or white nodules. It often breaks 
out afresh. Stricture not uncommon. 



The presence of tubercle bacilli is 
easily demonstrated at time of autopsy. 
Widal test negative. 

Evidence of tuberculosis elsewhere, 
especially in the lungs, can usually be 
found. 



1 After Woodhead, Practical Pathology, 3d edition, p. 455. 



DISEASES DUE TO PARASITES 



355 



(B) The spleen is enlarged, softened,, and hyperplastic, and 
infarcts are not uncommon. (C) The heart, liver, and kidneys 
not uncommonly show cloudy swelling. (D) The reaction in the 
muscles has been referred to on page 92. 

Complications. — (A) Intestines. Necrosis and suppuration may 
occur as extensions. The mesenteric glands may suppurate. A 
Meckel's diverticulum may become perforated or strangulated, and 
thus cause death, as in one of my cases. 1 Rupture of the rectum has 
been found post mortem. (B) Liver. Hepatitis with great enlarge- 
ment has been reported not infrequently. Miliary abscesses may 
occur. (C) Kidney. Acute nephritis may occur; cystitis also is 
found. (D) Orchitis occurs, but rarely. (E) Respiratory Tract. 
Dryness of the mucous membranes, erosion of epithelium, suppura- 
tion of the nasal septum, and cicatricial adhesions may occur. Suppura- 
tion of the nasal accessory sinuses is not infrequent. The larynx 
may show ulcerations, usually on the posterior wall. Diphtheritic 
inflammation of larynx and pharynx is sometimes found. Bron- 
chitis, pleurisy, and hypostatic or catarrhal pneumonia are not un- 
usual. Abscess and gangrene of the lungs have been reported. (F) 
Phlebitis is very common. (G) Pericarditis and endocarditis may 
occur. (77) Bleeding of the skin, gangrene, and purpura are found. 
An eruption sometimes occurs over the buttocks and malleoli. (7) 
The voluntary muscles may show waxy degeneration and hemor- 
rhages. (7) Bones and Joints. Periostitis may occur, according to 
Elliott and Washburn most frequently in the tibia. They report also 
cases of felon in the index fingers. Others have reported affections 
of the ribs, costal cartilages, and sternum. Arthritis may occur. 
Typhoid spine is a painful complication, causing at times marked 
curvatures. 

Bacteria of the Typhoid Group Causing Disease. — The 
Bacterium coli commune is constantly present in the intestine of 
man, and is a frequent invader of the internal organs, especially 
when intestinal lesions are present. The lesions which in certain cases 
are without doubt due to this bacillus are, (a) cystitis and pyelone- 
phritis; (b) inflammation of the biliary passages; the organisms 
have been found in the centre of gall-stones; (c) peritonitis; (d) 
appendicitis; (e) in some cases of a general infection resembling 



1 Philadelphia Hospital Reports, 1893, vol. ii, p. 140. 



356 POST-MORTEM EXAMINATIONS 

typhoid fever, this bacillus has been obtained in pure culture from the 
blood. Among other conditions which have in certain cases been attrib- 
uted to it are, puerperal infections, endocarditis, meningitis, tropical 
abscess of the liver, bronchopneumonia, putrid bronchitis, cholera 
infantum, and dysentery. 

For an account of the lesions due to the paratyphoid, see p. 181. 

Typhus Fever is an infectious disease, characterized by a sudden 
onset, a macular rash, nervous symptoms, and a cyclic course ending 
in crisis. No micro-organism has as yet been demonstrated as the 
cause of typhus fever, though several have been described as having 
been isolated from those affected with this disease. 

Lesions. — No characteristic lesions are found post mortem, and 
the anatomic changes are simply those produced by severe fever. 
{A) The blood is dark and fluid. (B) The entire body tends to 
rapid putrefaction. (C) The voluntary muscles may undergo waxy 
and granular degeneration. (D) The brain and meninges are con- 
gested. (E) The mucous membranes of the mouth and the respira- 
tory tract may show catarrhal inflammation. (F) The heart- 
muscle may be soft and flabby, and the endocardium, as well as the 
lining of the great vessels, may be stained bright red. (G) The 
organs may undergo parenchymatous degeneration. 

Varicella (Chicken-pox) is an acute contagious disease of 
childhood, characterized by a papular and vesicular rash; its cause 
is unknown. The disease is rarely fatal and is therefore not often 
seen post mortem. 

Lesions. — (a) The chief lesion is a cutaneous rash, consisting of 
raised red papules which in a few hours become vesicular, and in 
four days are converted into mahogany-brown crusts. Chicken-pox 
may appear coincident with smallpox. In tuberculous patients, gan- 
grene may occur about the vesicles, (b) Nephritis is the only other 
lesion found. 

Vaccinia is a local disease due to inoculation with the virus of 
cow-pox; it is characterized by a single lesion like that of smallpox, 
with slight constitutional disturbances. In rare instances, the pock 
may recur at irregular intervals, or may become generalized; gen- 
eralization usually occurs the eighth day, on the back and wrists. 
Vaccinia is seldom fatal, except with children. American Medicine 
(1902) reports a case of generalized vaccinia, due very largely to 
scratching, by which fresh inoculations were made. The pitting is 
as marked as in smallpox. 



DISEASES DUE TO PARASITES 



357 



Yellow Fever is an infectious tropical disease, due to an un- 
identified organism, the only known natural way of transmission being 
by a variety of mosquito, the Stegomyia fasciata. The formerly 
much discussed Bacillus X of Sternberg and the Bacillus ictero'ides of 
Sanarelli, sometimes considered to be identical, are no longer thought 
to be the cause of yellow fever. The interesting work done by Reed, 
Carroll, and Agramonte, in Havana, showing the true etiologic signifi- 
cance of the mosquito in this affection, is one of the most important 
contributions to medical science during the past decade, and renders 
them well worthy of the Nobel prize. 

Lesions. — {A) The skin is more or less jaundiced, and is some- 
times ecchymotic. (B) The blood is tarry in consistency. (C) The 
stomach and intestines may be hypersemic, or may show a catarrhal 
or at times hemorrhagic inflammation. The stomach contains a tarry 
fluid. (D) The liver and heart show high-grade fatty degenera- 
tion, with areas of necrosis. (E) The kidneys show diffuse nephritis 
with necrotic areas. 

PATHOGENIC ANIMAL PARASITES. 

I. Pediculi. The Pediculus capitis marks a condition most fre- 
quent in children. The female louse measures from one and eight- 
tenths millimetres to two millimetres in length; the male is somewhat 
smaller. In copulation the male lies beneath the female. The color of 
the parasite varies directly with the color of the skin of the infected 
person. The ova are grayish glistening specks, each enclosed in a 
membrane; they are attached firmly at an acute angle to the shaft of 
a hair not far from its root, the opening through which the parasite 
escapes being turned away from the scalp. The animals cause con- 
siderable irritation and arouse a pustular eczematous eruption. In 
severe cases the hair on the back of the head may be found matted 
with soft yellow crusts, while the scalp is covered with moist red 
granulations. The posterior cervical lymphatic glands are 
enlarged, and may first call attention to this affection. The Pedic- 
ulus pubis is smaller than the Pediculus capitis, and is somewhat 
triangular in shape. It infests regions where the hair is short, such 
as the axillary, pubic, and periocular regions. The parasite may 
be found at the root of the hair, its head buried in the follicle. An 
eczematous eruption results from the irritation. The Pediculus cor- 
poris (vestimenti) is the largest of these parasites, and differs slightly 



358 



POST-MORTEM EXAMINATIONS 



from those described above. It lives in the clothing when not in 
search of food on the body. By its constant irritation it causes derma- 
titis, and if present for a long time, pigmentation and thickening of 
the skin. 

II. The Cimex lectularius (common bedbug) produces an inflam- 
matory and somewhat hemorrhagic papule which disappears promptly. 
They probably transmit many diseases, as cerebrospinal meningitis, 
relapsing fever, tuberculosis, etc. 

III. Pulex irritans (the common flea) produces an erythematous 
spot with a minute central hemorrhagic point. An irritable wheal- 
like lesion may result. The Pulex penetrans (the sand-flea or jigger) 
is common in tropical and subtropical countries. It is smaller than 
the common flea. The pregnant female burrows under the skin, 
especially about the toes, and produces a pustular swelling which may 
ulcerate. The Pulex cheopsis may transmit plague. 

IV. The bite of Omithodorus savingnyi, a tick, is the cause of 
eight cases of fever, none of which was fatal, reported by Ross and 
Milne. 1 

V. The Sarcoptes (Acarus) scabiei (itch-mite) is a pearly white 
arachnid, the female being about .45 millimetres long and .35 milli- 
metres broad ; the male is about one-half this size. The female para- 
sites only are found in the skin, chiefly where it is moist, as in the 
webs of the fingers and toes, the flexor surfaces of the wrists, about 
the mammae in the female, and on the shaft of the penis in the male. 
The burrows are the characteristic lesion ; they are thread-like forma- 
tions, tortuous or straight, dotted, slightly elevated, and blackish, and 
from one-eighth to one-half inch in length. They are made by the 
impregnated female, which penetrates the epidermis obliquely to the 
rete, depositing as it goes excrement as well as ten or fifteen ova. 
Eczema, which may mask the burrow formation, develops as a conse- 
quence of the irritation. 

VI. The Demodex folliculorum, a species of acarus, is a worm-like 
body, .3 millimetres to .4 millimetres long. It is found in the hair- 
follicles in the skin disease called comedo, which is characterized 
by the formation of yellowish or blackish elevations of the size of a 
pin-head, corresponding to the gland-orifices. Some deny the etiologic 
significance of the parasite to this disease. 

1 Brit. Med. Jour., November 26, 1904, p. 1453. 



DISEASES DUE TO PARASITES 



359 



VII. The Pentastoma tcenitoides is a worm-like ascarid, the male 
of which is from eighteen to twenty millimetres long, while the 
female varies between seventy and one hundred and thirty millimetres. 
The larvae are five millimetres long. The larval form occurs encysted 
in the liver, and the adult form is found in the frontal sinuses of 
dogs and wolves. P. constrictum also occurs. 

VIII. The most important of the parasitic infusoria are, (i) 
Cercomonas intestinalis, which is found in faeces of diarrhoea, cholera, 
and typhoid fever; (2) Trichomonas vaginalis, which occurs in the 
secretion of the vagina, in the urine, and in the sputum; and (3) 
Paramecium (Balantidium) coli, found in the faeces of diarrhoea 
and the sputa from abscess of the lung. It has been known since 1857 
that this oval-shaped ciliated infusorion, which measures about one 
millimetre in length, may cause intestinal infection in man. The 
disease is also present in swine and in the orang-outang. 

Myiasis. — A condition caused by the larvae of certain flesh-flies, 
of the common house-fly, or of the bot-flies of oxen or sheep. The 
ova of these flies may be deposited in the nostrils, ears, or conjunc- 
tiva, in open wounds, or even in the vagina during the puerperium, 
and there develop into larvae, which live on the mucous membrane of 
the part. They may even destroy bone-cartilage and muscle. 

Cestodes (Tapeworms). — I. The Tcenia solium is introduced into 
the human digestive tract by the ingestion of so-called " measly" 
pork, which contains the embryo, the pig being the intermediate host. 
In the mature form the worm may be twelve feet or even more in 
length, and several may infest the intestines at one time. It is com- 
posed of numerous segments about one-third inch long and averaging 
one-fourth inch in width. The head is very minute, no larger than 
that of a pin, and bears four suckers; in front is a rostellum, and at 
the base of this is a double row of hooklets. The genital pore is mar- 
ginal, and leads to a linear uterus. The worm is hermaphroditic. 
When mature, thousands of ova are passed by the rectum. The 
embryo has six hooklets. It penetrates the walls of the stomach and 
burrows into the tissues of the animal that, has swallowed it. The 
Cysticercus cellulose?, the larval form of the Tcenia solium, is found 
in the muscles, brain, cord, peritoneum, or almost any other 
tissue of the affected animal. The surrounding capsule is frequently 
calcified. 

II. The Tcenia saginata is introduced into the human digestive 



360 POST-MORTEM EXAMINATIONS 

tract by the ingestion of raw beef, the ox being the intermediate 
host. It is larger, longer, and of more frequent occurrence in this 
country than the Taenia solium. The head is nearly square, and 
measures more than two millimetres in breadth, but has no hooklets. 
The segments are larger than those of the Taenia solium. The repro- 
ductive organs are on the ventral aspects of the segments, in the 
median lines. 

III. The Bothriocephalus latus is the largest and longest of the 
flatworms, being in the mature state twenty-five feet or more in 
length; it may have over 4000 segments. It has no hooklets, but is 
furnished with slit-like fossae on the head, which act as suckers. The 
genital pore is central. The embryo has six hooks and ciliated pro- 
longations. This parasite may occur in dogs and cats. 

IV. The Taenia Havopunctata is very rare. It is about sixteen 
centimetres long. 

V. The Taenia echinococcus is a very small, thread-like tapeworm, 
being from three to six millimetres in length and having only three 
segments. The last segment contains the generative organs and 
genital opening. It is thrown off when the ova are ripe, and 
may be found in the faeces. The head has four suckers, a rostellum, 
and a double row of hooklets. The embryos (scolices) are found in 
the ox, hog, sheep, and horse, and in man. Echinococcus disease is 
found most frequently in those countries, as Iceland, Northern 
Europe, and Australia, where the dog in which the worm takes 
growth lives in intimate association with man ; 1 it is characterized by 
the formation of endogenous or exogenous multilocular cysts in 
various portions of the body, most commonly in the liver, but also 
in the lung and pleura, the intestinal tract, the kidney, the 
bladder, the genitalia, the brain, etc. The embryo, freed from the 
cyst by digestion in the stomach, burrows through the intestinal wall 
and is carried to the various organs ; it then loses its hooklets and is 
gradually converted into a cyst (hydatid) having two walls, of 
which the external is laminated, and the internal is granular or paren- 
chymatous, containing blood-vessels and muscle-fibres. The interior 
is filled with a clear non-albuminous fluid, of specific gravity 1.005- 
1.009, usually containing sugar and hooklets. From irritation of the 



1 According to Senn the worm is not found in Eskimo dogs and Arctic hares 
{Jr. Atner. Med. Assoc, November 25, 1905). 



DISEASES DUE TO PARASITES 361 

surrounding tissues a fibrous capsule generally develops on the outside. 
The cysts vary in size from that of a small pea to that of a child's 
head. From the inner (parenchymatous) layer may develop brood 
capsules, which in their turn produce numerous scolices. The cysts 
grow slowly, and when the embryo dies, the whole may become calci- 
fied. Sometimes the cysts suppurate; occasionally they rupture into 
the adjacent structures. 

VI. Other tapeworms, as the Taenia pisiformis, Tcenia nana, 
Taenia cncumerina, Bothriocephalus mansoni, and Tcenia madagas- 
cariensis, are very rare except in the tropics. 

In the making of many autopsies it is surprising how few taeniae 
are found in the intestinal tract. My experience comprises but two 
cases. One of these was that of a man who committed suicide with 
opium. Two Teenies saginatee were found, the head of the first one 
being firmly attached beneath a fold of one of the valvulae conniventes, 
high up in the jejunum, and the other, five or six feet further down the 
intestine, the segments of both worms then continuing on down to 
near the ileocaecal valve. 

Nematodes (Round Worms). — I. The Ascaris lumbricoides is 
a cylindrical worm with both ends pointed ; the head ends in three lips. 
The female is from ten to sixteen inches in length, the male consider- 
ably smaller. It is brownish yellow, reddish, or white in color. It may 
be found in great numbers in the intestinal canal, and has been 
known to wander into the stomach, and exceptionally into the mouth, 

NOSE, BRONCHI, GALL-PASSAGES, PERITONEAL CAVITY, etc. This IS 

especially apt to be the case after death. 

II. The Oxynris vermicularis {Seat-worm) is a very small round 
worm, about 10 mm. long. The eggs are oval, are about 0.05 mm. 
long, and are produced in great numbers. These worms are very 
common in children, occurring in the caecum, colon, and rectum. 
In very severe cases they may be found in any part of the alimentary 
tract and in the vagina and bladder. A pustular eruption around 
the anus is often produced. 

III. The Trichina spiralis is a dangerous and common parasite, 
ingested by man in insufficiently cooked pork, the muscle of the dis- 
eased pig containing the embryo in encysted form. The embryonic 
capsule is dissolved in the stomach and the embryos thus set free 
grow and multiply rapidly. The tiny worms find their way through 
the walls of the gut to various parts of the body. They enter the 



$62 POST-MORTEM EXAMINATIONS 

striated muscles, disintegrate the substance, and coil within the 
sarcolemma, there becoming surrounded by a capsule which sub- 
sequently calcifies. Resulting lesions may be acute catarrhal enteritis, 
oedema, bronchopneumonia, and fatty degeneration of the liver. The 
lymphatic glands, blood, and marrow may contain eosinophiles in 
great numbers during life, but after death these are diminished or 
absent. In severe cases, these cells accumulate in the lungs until the 
collection resembles a small abscess. 

IV. The Ankylostomum duodenale {Uncinaria duodenalis; in 
America, the Uncinaria Americana) lives in the upper part of 
the intestines, but is seldom found below the duodenum. The 
female is the larger, and varies from ten to sixteen millimetres 
in length. At the anterior portion of its head are hooklets, 
with which it attaches itself to the intestinal walls. It is frequently 
associated with Egyptian chlorosis. Stiles and Harris have recently 
called attention to the wide distribution of uncinariasis in the South ; 
which disease may be readily recognized by finding the ova in the 
faeces. At autopsy, catarrhal gastro- enteritis with hemorrhagic spots 
is found. Adult worms, from i to iooo in number, may be found in 
the duodenum, with their heads buried in the mucosa. The subcu- 
taneous tissue is cedematous, and there is effusion into serous sacs. 
Calmette x has infected young dogs with the human and the canine 
ankylostoma by way of the skin, while Claude A. Smith has shown 
experimentally that infected dirt rubbed on the healthy skin of the 
hand is capable of causing inoculation, the disease subsequently being 
cured by thymol. 

V. The embryo of the Filaria sanguinis hominis is a round 
worm, one seventy-fifth to one one-hundredth of an inch long, enclosed 
in a delicate sheath. It circulates freely in the blood, but only at night. 
The adult parasite is located in the lymphatic vessels, and owing 
to the obstruction and local irritation which its presence produces it 
may give rise to chylous ascites, lymphangiectasis, oedema, abscesses, 
and perhaps elephantiasis. The worm is introduced into the body by 
the mosquito. 

VI. The Trichocephalus dispar {Whip-worm), a small worm, 
thick at one end and thread-like at the other, is found in the 
large intestine, colon, and cecum. It is a frequent cause of 
anaemia. 

1 Bull, de I'acad. de med., 1905, vol. lxix, no. 12. 



DISEASES DUE TO PARASITES 363 

VII. The Rhabdonema intestinale is a minute slender worm, 
measuring two millimetres by six one-hundredths of a millimetre. 
The female has a string of five or six ellipsoidal eggs, each measuring 
one one-hundredth by thirty-four one-thousandths of a millimetre. 

VIII. The Strongylus subtilis is found only in Egypt, and is 
not important. 

Trematodes (Flukes). — These worms are lanceolate in shape, 
quite flat, and possess a distinct head and neck. They are three- 
fourths of an inch long and about half an inch broad. The color 
is dull brown. The Distoma is the most common genus found 
in man. 

I. The Distoma haematobium {Blood-fluke) has two suckers, one 
near the mouth and the other near the ventral portion of the body. 
The female has a grooved channel posteriorly for the reception of the 
male. This parasite is found chiefly in the portal system and in 
the veins of the bladder. The ova are found in the urine; they are 
elongated ovoid bodies, sharply pointed at one extremity, and con- 
taining black pigment, and can easily be seen with a low power of 
the microscope. 

II. The Distoma hepaticum (Liver-fluke) is ingested in the form of 
ova attached to waterplants, and infests the upper intestine, the 
bile ducts, the gall-bladder, and the liver. It causes the " liver- 
rot" in sheep. 

III. The Paragonimns Westermanii causes parasitic hcemoptysis, 
which now occurs in America as well as in Asia. The eggs are 
found in the sputum, and the fluke measures from eight to sixteen 
millimetres in length by four to eight millimetres in breadth. 

IV. The Distoma ophthalmobium and the Distoma ringeri have 
been described as occurring in the eye and the lung. 

V. The Schistosoma Cattoi, or vS\ japonicum, is a new form of 
blood-fluke discovered by Catto. 1 The post-mortem examination of 
a Chinaman from Fukien Province, who died of cholera after a three 
days' illness, showed a large amount of adipose tissue throughout the 
body, an enlarged liver and spleen, a thickening of the walls of the 
gall-bladder, indications of repeated attacks of peritonitis, and a 
thickening of the intestinal walls which increased towards the lower 
portion of bowel until the rectal walls were three-fourths of an inch 

1 Jr. Amer. Med. Assoc. February 4, 1905. 



364 POST-MORTEM EXAMINATIONS 

thick. The stomach, pancreas, suprarenals, kidneys, heart, lungs, 
and the mucous membrane of the bladder were not involved. On 
section, a number of adult trematodes were found in the blood-vessels 
of the mesocolon, the filariform embryo and ova were present in the 
mucosa and villi of the large intestine, and numerous small oval 
bodies having a smooth stout capsule were discovered in the liver and 
the mesenteric lymph glands. These were identical with the ova 
found in the uterus of the female. This new blood parasite resembles 
the Schistosoma hcematobium in a general way, but differs from it 
in an apparent preference for the arterial instead of the venous 
channels as a habitat, and in its selection of the alimentary tract 
instead of the urinary system as the avenue of escape for the ova. 
A second case has been described by Henry G. Beyer in American 
Medicine for September 30, 1905. 

AmcebtE coli are considered on page 315. 

H^MATOZOA. 

Malaria. 1 — This widely distributed and much studied infectious 
disease is due to a hsematozoon, the Plasmodium malaria, and is trans- 
mitted to man by the Anophelina mosquito. The disease is char- 
acterized by a chill followed by fever, and by a period of remission. 
Schilling 2 reports a case of tertian fever occurring eight and one-half 
months after the patient had left Africa, and two and one-half years 
after his last attack, although no opportunity of becoming reinfected 
existed in the meantime. Negroes may have the malarial parasites 
in their blood without showing any symptoms of the disease. Accord- 
ing to Celli, the eggs of the Anopheles claviger, at a temperature of 
20°-25° C. develop in about one month into insects, which in another 
thirty days lay eggs. The aestivo-autumnal parasites, at a tempera- 
ture of 30 ° C, undergo their entire development, including the 
formation of sporozoits, in about one week. 

Lesions. — (a) In acute malarial fever, which may be quotidian, 
tertian, or quartan, uncomplicated cases are rarely fatal. The blood 
shows disintegration of the red corpuscles, and an accumulation of 

1 Laveran's earliest works are : Nature parasitaire des accidents de I'impalu- 
disme, Paris, 1881 ; Traite des fievres palustres, 1884. An excellent diagram show- 
ing the cycle of development of this parasite will be found on page 259 of Green's 
Pathology and Morbid Anatomy (1905). 

2 Deut. med. Wchnschr., March 5, 1903. 



DISEASES DUE TO PARASITES 



365 



pigment is thereby formed. The spleen is enlarged, dark in color, 
and may show pigmentary deposits, (b) In pernicious malaria the 
blood contains enormous numbers of the parasites, though at the 
postmortem most careful search may fail to reveal Laveran's 
organism. The red corpuscles are in all stages of destruction, and 
the serum is tinged with haemoglobin. Hydraemia is marked. The 
spleen is moderately enlarged. The pulp is soft, chocolate-colored, 
and turbid, containing large numbers of red corpuscles and parasites 
and a greatly increased amount of pigment. The liver is swollen 
and presents areas of focal necrosis and capillary thrombosis. The 
gastro-intestinal mucous membrane is congested; the capillaries 
may contain numerous haematozoa, and thrombosis may cause ulcera- 
tions of the mucosa. Pigmentary deposits are also common. The 
kidneys present a more or less parenchymatous change, with only 
moderate pigmentation. The brain may show thrombosis (due to 
the parasites), with secondary softening of the surrounding tissue. 
There may be advanced fatty degeneration of the heart, (c) In 
chronic malarial cachexia the blood presents all the characteristics of 
an advanced anaemia, the disease often being distinguishable from 
pernicious anaemia only by the presence of the parasite, and by icterus. 
The spleen is greatly enlarged, weighing in certain cases from seven 
to ten pounds, and is firm and resistant to the knife. The capsule 
is thickened, and the parenchyma is brownish or slate-colored, with 
areas of pigmentation. The kidneys are enlarged, and of a grayish- 
red color. The peritoneum is thickened, opaque, and of a deep slate 
color; and the gastric and intestinal mucous membranes have 
sometimes the same hue. The gray matter of the brain is of a deep 
reddish-gray color, or in very chronic cases, a chocolate brown. The 
meninges are congested, (d) In the cestivo-autumnal form, cirrhosis 
of the liver is sometimes found. Very extensive pigmentation may 
occur. Pneumonia is believed to be common. Rupture of the cap- 
sule of the enlarged spleen may occur, followed by hemorrhage into 
the peritoneum, and even by peritonitis. Moderate albuminuria 
is frequent; acute nephritis may follow long-continued or repeated 
infection. 

Psorospermosis is a condition produced by the presence of oval 
transparent bodies belonging to the Coccidia, to which class the 
malarial organism also belongs. 

Lesions. — I. Internal form. (A) The liver may be enlarged, 



366 POST-MORTEM EXAMINATIONS 

and may contain caseous foci surrounded by areas of congestion. 
In the majority of cases it has been found to contain the organisms. 
(B) Upon the peritoneum, omentum, and pericardium have been 
found whitish growths resembling tubercles, and containing the 
coccidia. (C) In the spleen, kidneys, and ureters similar masses 
have been found. 

II. Cutaneous form. The lesions closely resemble those of tuber- 
culosis of the skin. The organisms are found in Paget' s disease of 
the nipple, and by some are believed to be its cause. In some cases 
of molluscum contagiosum, they are also present. The cutaneous 
disease is always associated with internal lesions. 

A case has been reported in which at autopsy nodules were found 
in the lungs, adrenals, testicles, and spleen, on the surface of the 
liver, and on the pleura. Great numbers of the sporozoa were 
found in the lesions. Successful inoculations have been made into 
rabbits and dogs. 

Trypanosoma. — Four animal diseases, nagana, surra, mal de 
caderas, and dourine, 1 are caused by varieties of trypanosomes. 
Recently Nepveu, Dutton, and others have found these parasites in 
man, and the sleeping sickness and the so-called trypanosoma fever 
(different stages of the same disease) are due to the entrance into 
the blood and cerebrospinal fluids of Trypanosoma gambiense. These 
organisms are transmitted to human beings by tsetse flies (Glossina 
palpalis). Monkeys, dogs, cows, horses, and rats are also susceptible 
to certain species. Trypanosoma Lewisi infests the rat and is trans- 
mitted by fleas and lice. T. Evansi, T. Brucei, and Equinum equiper- 
dum attack horses, and the T. disea infests birds. The tsetse fly 
carries the human parasite and the T. Brucei. These parasites are 
fusiform flagellated protozoa, several times larger than a blood- 
corpuscle. Along one margin an undulating membrane extends from 
the centrosome to the anterior end of the body, where it becomes a 
true flagellum. The parasite is non-sexual, reproducing by longi- 
tudinal division. It lives in the blood serum and attacks the red cells. 
The tsetse fly can carry the infection from sick to healthy up to forty- 
eight hours after having fed. Artificial cultivation to the hundredth 
generation of the T. Lewisi from the rat has been made lately by 



1 An historical account of this disease, by Koch, will be found in the Lancet, 
November 26, 1904. 



DISEASES DUE TO PARASITES 367 

McNeal and Novy, 1 and the first strictly pure cultures of the patho- 
genic animal parasite have thus been obtained. The agglutination 
reaction occurs under proper conditions. Coplin 2 showed these 
organisms from rats caught in the Philadelphia Hospital, and also 
a slide of the lungs evidencing pneumonic changes. Ehrlich and 
Shiga, experimenting with the organism, found that the stain trypan 
red was able to destroy the trypanosomes in mice and to protect them 
against relapses; the stain was equally effective when given by the 
stomach. The skin is well reddened in eight minutes and reaches a 
maximum color in twelve hours, and the tint remains for from six to 
eight weeks, longer in the internal organs. This stain has little or 
no effect on rats, guinea-pigs, or dogs. 3 

The Leishman-Donovan bodies were first found in the spleen. 
These parasites are by no means uncommon in the tropics, and are 
situated intracellularly in large mononuclear macrophages. Rogers 
has recently announced that trypanosomes develop upon culture of 
these bodies. Other observers still oppose this view, and believe 
the Leishman-Donovan bodies to be an entirely new genus of hsema- 
tozoa, to infection with which may be attributed the so-called " Dum- 
dum fever" and the Delhi boil of India, and the " Kala-azar" of Assam. 
The bodies have been found in blood obtained by splenopuncture 
intra vitam, as well as post mortem from the spleen, liver, kidneys, 
mesenteric glands, walls of intestinal ulcers, and skin lesions. It has 
been suggested that the splenomegalies seen in this country may be due 
to infection with this parasite. 

1 Vaughan , s Dedication Volume of Medical Research, 1903. 

2 Phila. Path. Soc, December 10, 1903. 

3 Berl. klin. Wchnschr., March 28, 1904, p. 239 ; April 4, 1904, p. 362. 



CHAPTER XXII 

THE PREPARATION OF TISSUES FOR MICROSCOPIC AND MACROSCOPIC 

OBSERVATION 1 

Method of Examining Scrapings at the Autopsy. — Scrap- 
ings from fresh tissue are best collected by a sterilized platinum 
scoop, or they may be secured by scraping the tissue with a small 
scalpel. The material thus collected is to be at once transferred to 
a slide containing a small amount of the physiologic sodium-chlorid 
solution, prepared in the strength of 0.9 per cent, for warm-blooded 
animals and 0.6 per cent, for cold-blooded ones. A much better solu- 
tion for this purpose, and one that should be kept ready for use in all 
laboratories, is sterile blood-serum or hydrocelic or ascitic fluid, which 
may be preserved until wanted for use in the special form of pipette 
described in the next chapter, upon " Bacteriologic Investigations." 
Fluids rich in cellular matter are best diluted with one or the other 
of the above-mentioned solutions. Those poor in cells are first to 
be centrifugated ; this is especially true in case an examination be 
desired of the apparently normal pericardial or cerebrospinal fluids. 
The hanging drop is an excellent means for the examination of such a 
mixture by the microscope. If the apparatus for this procedure is not at 
hand, the cover-glass may be raised by four or five small drops of seal- 
ing-wax so as to prevent pressure, or small pieces of a broken cover-glass 
may be so arranged as evenly to support the cover-glass. This is then 
surrounded by a ring of vaselin to prevent evaporation. An ingenious 
method of supporting the slide is described by Arnold, 2 in which elder- 
pith prepared in the form of rings supports the cover-glass, this porous 

1 Based on the works of Lee, The Microtomist's Vade Mecum; Mallory and 
Wright, Pathological Technique ; Apathy, Die Mikrotechnik der thierischen Mor- 
phologic; Fischer, Fixirung, Fdrbung, und Bau des Proto plasmas; Szymono- 
wicz, Lehrbuch der Histologic; Stohr, Text-book of Histology; Bohm and von 
Davidoff, Text-Book of Histology ; Lehrbuch der Klinischen Untersuchungsmetho- 
den; Die Encyklop'ddic der mikroskopischen Technik, 1903; and Schmorl, Die 
pathologisch-histologischen Untersuchungsmethoden, 1905. The ultraviolet micro- 
scope, which reveals particles with a linear diameter of 0.000001 millimetre, has 
already rendered valuable service in the securing of excellent photomicrographs. 

a Archiv. f. wissenschaftl. Mikrosk., vol. Hi (quoted by Schmorl). 
368 



PRESERVATION OF TISSUES 369 

material permitting the introduction of the stain through it from 
without. The materials especially employed for staining are neutral 
red, 0.01 to 0.1 per cent., and methylen blue dissolved in a 0.75 per 
cent, sodium-chlorid solution ; or o. 1 per cent, methylen green, Loffler's 
methylen blue, or a weak solution of acid fuchsin may be employed. 
Other agents — such as Lugol's solution, one-per-cent. osmic acid, and 
acetic acid — are also most useful. Bismarck brown and Van Gieson's 
stain are much to be desired when photomicrographs are to be 
taken, as the brown color is capable of giving good plates without 
the application of colored screens, as is necessary with many of the 
staining reagents. Solid tissues are teased in the physiologic salt 
solution, or for the purpose of quick maceration are mixed with a 
freshly prepared solution of sodium hydrate in the proportion of one to 
three. A trypsin preparation, such as pancreatin, may be employed 
to study artificial digestion, keratin, neurokeratin, and reticular fibrils 
alone remaining after the action of the trypsin. 

The method of preparing dry films is given on page 384. Jenner's 
fluid is most useful in the staining of such preparations. It is prepared 
as follows: 0.5 gramme of the eosinate of methylen blue is dissolved 
in 100 cubic centimetres of absolute methyl alcohol. A few drops of 
this stain are placed on the fixed or unfixed specimen, and allowed to 
act for from thirty seconds to two minutes. The slide is then washed 
several times in water. 

The Giemsa stain, so much spoken of in the staining of the 
Treponema pallidum of syphilis, may be purchased in the shops, or 
may be prepared as follows: Azur II eosin, 3.0 grammes; azur II, 0.8 
gramme. These are thoroughly dried over sulphuric acid in an 
exsiccator and then -finely powdered, preferably by passing through a 
silk sieve. The mixture is then dissolved in pure glycerin, 250 grammes, 
at a temperature of 60 ° C, and methyl alcohol, 250 grammes, heated 
to the same degree, is then added. The mixture is then put aside 
for twenty-four hours at room temperature, and then filtered. In 
practice the stain is used when diluted with water (one drop to one 
cubic centimetre of water), or with water rendered alkaline by a 
few drops of 0.0 1 per cent, solution of potassium carbonate. The 
film is best fixed in pure methyl alcohol, and staining takes place 
in from ten to fifteen minutes. The film is then washed in water 
and mounted in the usual way. ' Another method of staining this 

parasite is by silver nitrate, as in Golgi's method. 

24 



370 POST-MORTEM EXAMINATIONS 

Method of Preparing Frozen Sections. — There is nothing 
which adds so much interest to a postmortem as the immediate prepara- 
tion of frozen sections. This takes but ten or fifteen minutes and 
may be carried on by an assistant during the performance of the 
autopsy, and the slides may then be compared at once with the gross 
morbid lesion. Before the Philadelphia Pathological Society, on 
December 10, 1896, the author gave a demonstration of tissues 
prepared by ethyl and methyl chlorid as the freezing agent, and this 
method is to be recommended for those who do not have the more elab- 
orate apparatus necessary for the preparation of tissues by carbon 
dioxid or ether. The one objection is the cost of this method, which 
should not, however, be over six or seven cents for each slide pre- 
pared. If there be plenty of time, the pieces of tissue under examina- 
tion are fixed and hardened in Orth's fluid for three hours. At the end 
of this period they are removed and thoroughly washed in running 
water for several hours. Alcohol is gradually added until they are 
finally placed in absolute alcohol. The tissues are then washed in 
water and immersed in a solution of acacia and sugar, prepared as 
follows: Boil 28.5 grammes of lump sugar in 30 cubic centimetres of 
water, and when cool add 1 cubic centimetre of formalin. A mucilage 
of gum acacia, 1 part, and formalin ( 1 per cent. ) , 50 parts, is pre- 
pared without the aid of heat. Equal parts of these two solutions are 
mixed as needed, and diluted with water. The stronger the solution 
the more slowly will it freeze, but the less harm will it do to the 
tissues. This procedure takes twenty-four hours. If a quick method 
be desired, pieces of tissue 2 by 4 by 4 millimetres are placed in the 
formo-acacia fluid. They remain in the solution for ten minutes. If 
time presses, or in the event of an operation with the patient anaesthe- 
tized, this step may be omitted. The pieces of fresh tissue are at 
once frozen in this solution, or in one of dextrin, in the paraffin- 
holder of a microtome. A small stream of ethyl chlorid or methyl chlorid, 
or preferably a mixture of the two, is played from above directly upon 
the specimen at a distance of about one foot. The tube is moved from 
place to place until the specimen is firmly attached to its base of support. 
It is interesting to watch the freezing process start from the edges and 
.proceed towards the centre until the whole is coated with ice. Such 
crystals are extremely small and delicate and do not injure the 
tissues as in some other of the freezing methods; then, too, these 
chlorids possess definite fixing properties apparently not possessed 



PRESERVATION OF TISSUES 



371 



by carbon dioxid, though to a certain degree found in ether. Thirty 
seconds to a minute is usually sufficient to freeze the specimen. Such 
sections are at once transferred to a one per cent, sodium-chlorid 
solution, the heat of the finger being employed to melt the section 
if it become frozen to the knife. Any stain may next be employed. 
Sudan III gives good results, especially in tissues containing fat. 
Dr. Lewis B. Wilson * recommends that they be stained for from ten 
to twenty seconds by constant movement in a neutral polychrome- 
methylen blue solution. They are next washed in one per cent, 
sodium chlorid and mounted in the glucose solution. Wederhake 2 
puts the fresh frozen section, without rinsing, in tincture of iodin 
(2 to 5 drops in twenty cubic centimetres of water). The section is 
then transferred at once to a twenty per cent, dilution of a stain made 
by dissolving crocein scarlet 7 B in 10 cubic centimetres of 70 per 
cent, alcohol until the alcohol will not dissolve any more. It does 
not take up much. After from one-half to three or five minutes in 
the stain, the specimen, still held on the spatula, is rinsed and 
soaked in water for a minute or two — five minutes would probably 
dissolve out all the stain. The specimen is then allowed to slide off the 
spatula into a drop of glycerin on the object glass, when it is ready for 
the microscope after being covered with a cover-glass. If the speci- 
men is already fixed, it has to be soaked for two hours in forty per 
cent, formalin, and then rinsed in water for two hours, after which 
the technic is the same as for fresh specimens. If the results are not 
satisfactory, or to control them, the stain can be washed away with 
diluted ammonia and any other stain then used. 

Preservation of Tissues for Microscopic Study and the 
Choice of the Fixing Agent. — When tissues are to be preserved 
for microscopic study, the method of fixing and hardening them should 
be decided upon at the time of their removal from the body. The 
object to be attained by fixation and hardening is permanently to 
solidify the structural elements of a part as nearly as possible in their 
original form and situation and thus prevent both shrinkage and 
expansion. All our present methods, however, fail to give an accurate 
picture of the living cell, and not enough attention is now paid to the 
microscopic examination of fresh scrapings removed during the per- 



1 Jr. Amer. Med. Assoc, December 2, 1905. 

2 Centralbl. f. Gyn'dk., vol. xxix, no. 25. 



372 



POST-MORTEM EXAMINATIONS 



formance of the autopsy, when cloudy swelling, dropsical changes, 
and mucoid degeneration may be studied at their best. The use of 
as perfectly fresh tissues as possible for microscopic study is essential, 
for many structural details disappear upon molecular death. Fortu- 
nately, this does not occur until several hours after molar death, so that 
it is often possible to obtain tissues to all intents and purposes still 
living. Special attention should be paid to those tissues which have 
been stained or hardened by reagents introduced during life into the 
body under examination ; experimental staining of living tissue affords 
a most inviting field of original investigation. 

The wrapping of tissues in paper or cloth for transporting them 
to a distance is to be regarded only as a last resort. When this is 
done, pieces of. sufficient size to insure preservation of their interior 
intact are enveloped in an abundant supply of clean cotton (antiseptic 
gauze causes markings on them), moistened very slightly with a 
i-iooo bichlorid solution, which will act as a preservative, prevent the 
subsequent adherence of the cover to the specimen, and thoroughly 
protect it from pressure; these segments are cut down to a proper size 
before they are put into the fixing agent in the laboratory. 

Bottles containing the more common fixatives should be ready, 
and as soon as the tissues are exposed and described, — before the part 
becomes distorted, fluids escape, or surfaces dry, — they should be cut 
with a clean, sharp knife into pieces of not over one-fourth to three- 
eighths inch in thickness. I sometimes cut the pieces in different shapes, 
each piece representing an organ or part, and always use the same 
shape for the same part. Sections of organs should include their 
characteristic structures, — cortex, capsule, hilum, endocardium, etc. 
Sections of tumors should be taken from the centre, where degenera- 
tive changes are most marked, and from the growing peripheral 
margin, if possible including some normal tissue; this is of especial 
importance in the case of malignant tumors. Mucous and serous mem- 
branes are pinned out on cork with hedgehog bristles or other non- 
corroding substance (as horn, or wood that will give no stain when 
soaked in the preservative fluid to be used), with their secreting 
surfaces uppermost. Muscle-fibres are best preserved by being tightly 
stretched upon and tied at the ends of a piece of wood. The segments 
of tissue, without being touched by either fingers or forceps, are lifted 
on the blade of the scalpel and dropped immediately into a bottle con- 
taining an amount of fixing fluid far in excess of their bulk. Of 



PRESERVATION OF TISSUES 



373 



energetic fixatives, such as Flemming's or Hermann's, about fifteen 
times the volume of the object introduced will suffice, while of milder 
fluids, like the bichromate of potassium or picric acid solutions, twenty 
to fifty times such volume may be employed with advantage. As the 
method of staining to be employed is not always known, it is wise to 
harden portions of important tissue in alcohol, corrosive sublimate, 
formalin, and osmic acid. 

If the different tissues are distinguishable macroscopically, they 
may be placed in the same jar ; if not, separate bottles are better. Tags 
may be attached, the writing being done with a lead-pencil, so as not 
to be acted upon by the usual preservatives. The jars are labelled with 
the date, the number or name of the autopsy, and the fixative used. 
It is often of importance to add the exact locality from which the 
pieces have been removed and the plane on which they are to be cut 
when placed in the microtome. 

The fluid should always be changed after it becomes turbid; or 
in the case of alcohol or formalin, preferably after three hours, whether 
it is turbid or not. If the specimens are to be sent away, they should 
not go until the fluid remains clear; if the time necessary for trans- 
portation exceeds that of the proper action of the fixative, they should 
be worked up to 80 per cent, alcohol by thorough washing in water for 
several hours, and then in successive strengths of alcohol, 33%, 50, 70 
per cent., and shipped in that fluid, carefully protected by being sur- 
rounded with absorbent cotton. 

The choice of a fixing agent is determined by the nature of the 
object to be preserved and the purpose for which the investigation 
is undertaken. Certain fixing agents, such as osmic acid, chromic 
acid, potassium bichromate, and corrosive sublimate solutions, seem 
to form a chemic union with the cell contents and so produce an 
extremely durable insolubility. Others, such as picric acid and nitric 
acid, harden well, but form such unstable compounds that the fixation 
is easily removed by washing in water and must be preserved by 
placing the specimens in alcohol. It is evident that any solvent action 
by the reagent — e.g., the action of alcohol on fat and that of acetic 
acid on protoplasm — lessens their practical value. The characteristics 
of different pathologic conditions are better brought out in some 
fixatives than in others. Thus, fatty degenerations are well preserved 
by an osmic acid, bichromate, or formalin solution; cedematous and 
parenchymatous changes, by corrosive sublimate; fibrin, hemorrhagic 



374 



POST-MORTEM EXAMINATIONS 



conditions, and bacterial invasions, by absolute alcohol. Moreover, 
different tissues require different treatment : the fixation of a lymph- 
node is quite a different matter from that of a retina. Then the purpose 
for which the examination is made will largely influence the choice. 
If it be simply a question of general diagnosis, Orth's fluid and 
alcohol will answer every purpose; by the use of alcohol we can pre- 
serve the specific staining properties of micro-organisms and haemo- 
globin and various important chemic reactions, and by the use of 
Orth's fluid colloid and mucoid material retain their transparency, 
fat is preserved, etc. 

If we undertake the investigation of pathologic processes and the 
comparison of abnormal with normal cellular anatomy, then special fix- 
atives must be used. Full descriptions of such methods will be found 
in the books of reference mentioned at the beginning of this chapter. 

Optical Differentiation. — Some agents in producing insolu- 
bility effect another change which is equally valuable and which is 
known as optical differentiation. The various cell structures respond 
differently to the fixative. Their indices of refraction are altered; 
some are raised, some lowered, and marked contrasts in refractive 
properties are developed throughout the cell. In this way structures 
become visible that were before unseen. Bichromate of potassium 
stiffens very equably, with neither shrinkage nor expansion, but has 
no power of optical differentiation; while osmic acid possesses this 
in a high degree. Since observation with the microscope is directly 
dependent upon differences in refraction, it is evident that this is a 
most valuable property of a fixative. 

Penetration. — The ability to reach all points of the tissue at the 
same time is another important characteristic of a fixing agent and 
one clearly connected with securing optical differentiation. Osmic 
acid has but little penetration. If pieces placed in its solutions are 
too thick or remain therein too long, the superficial layers become 
overexposed, the indices of refraction are all equally raised, and 
differentiation disappears. This is true not only of cells in mass, but 
also of intracellular structures. Prompt and uniform action, the sharp 
fixation of tissues at the precise moment, insures good optical differ- 
entiation; on the other hand, slow, unequal action results in loss of 
definition. 

Formulas of some of the many solutions useful for preparing 
tissues for microscopic study will be found upon the next page. 



PRESERVATION OF TISSUES 



375 






Muller's Fluid. 
Bichromate of potassium 2.5 grammes. 

Sodium sulphate 1. gramme. 

Water 100. c.c. 

Formerly the most used of all such 
solutions. Now largely replaced by, or 
used with, formalin. 

Flem ming's Solution. 

Chromic acid, 1 per cent 45 c.c. 

Osmic acid, 2 per cent 12 c.c. 

Glacial acetic acid 3 c.c. 

Prepare just before using. Small 
pieces of tissue are hardened in from 
several hours to two days. Nuclear 
figures are especially brought out. Saf- 
ranin is a good stain afterwards. 

Altmann's Solution. 
Osmic acid, 2 per cent., 
Potassium bichromate, 5 per cent. 

Mix equal parts as needed. Wash 
thoroughly and place in alcohol. 

Erlicki's Solution. 
Potassium bichromate.... 2.5 grammes. 
Copper sulphate... 0.5 to 1. gramme. 

Water 100. c.c. 

An extremely good and cheap solution 
for hardening voluminous objects. It is 
used as a fixative for Freud's gold stain 
for nerve-fibres. 

Carnoy's Fluid. 

Glacial acetic acid 1 part. 

Absolute alcohol 6 parts. 

Chloroform 3 parts. 

Leave pieces in from fifteen to thirty 
minutes ; transfer to absolute alcohol ; 
avoid aqueous liquids. 

For Golgi's slow method the tissues are hardened in two per cent, 
bichromate solution. For his quick method, use osmic acid, 1 per 
cent., 1 part, and bichromate of potassium, 3.5 per cent., 4 parts. For 
Nissl, employ absolute alcohol. Do not use bichromate of potassium. 
For Marchi use Muller's fluid. For Weigert's fibrin method harden in 
alcohol, corrosive sublimate, formalin, Orth, or Miiller. For Weigert's 
nerve stain use five per cent, formalin. For Mallory's stain, ten per 
cent, formalin in a saturated aqueous solution of picric acid. 



Orth's Fluid. 

Potassium bichromate 2.5 parts. 

Sodium sulphate 1. part. 

Water 100. parts. 

Formalin ; add before using 10. c.c. 

After hardening the tissues are to be 
thoroughly washed in running water. 

Zenker's Fluid. 
Corrosive sublimate.... 5. grammes. 
Potassium bichromate. . 2.5 grammes. 

Sodium sulphate 1. gramme. 

Water 100. c.c. 

Dissolve by heat and add before using 
5 c.c. of acetic acid. Tissues remain 
here for twenty-four hours and are next 
washed in running water for a similar 
period of time, and then transferred to 
35-70-95 per cent, alcohol. 

Hermann's Solution. 
Platinic chlorid, 1 per cent... 15 parts. 

Glacial acetic acid 1 part. 

Osmic acid, 2 per cent 2-4 parts. 

One of the best hardening and fixing 
solutions known. 

Lindsay Johnson's Mixture. 
Potassium bichromate, 2.5 per 

cent 70 parts. 

Osmic acid, 2 per cent 10 parts. 

Platinic chlorid, 1 per cent 15 parts. 

Acetic or formic acid 5 parts. 

Add the acetic or formic acid just 
before using. A fine fixative for deli- 
cate objects, such as a retina. Leave 
objects in for two hours. Wash in run- 
ning water. Harden in alcohol. 
Gilson's Solution. 

Absolute alcohol 1 part. 

Glacial acetic acid 1 part. 

Chloroform 1 part. 

Corrosive sublimate to saturation. 



376 



POST-MORTEM EXAMINATIONS 



Decalcification. — In my hands the following, of the many 
methods recommended, has given good results: Nitric acid, five per 
cent, by weight, to which may be directly added an equal part of sat- 
urated potassium-alum solution, or five parts of ten per cent, formalin 
to one of five per cent, nitric acid. 

Thomas's method is to harden in alcohol ; then decalcify in alcohol, 
five parts, and nitric acid, one part (add carefully), changing the 
fluid frequently. When decalcified — three to four weeks for small 
objects — transfer to different alcohol until it is no longer acid. Deli- 
cate bones, such as those of the ear, can best be mounted in celloidin and 
then decalcified. 

Preparation of Tissues for Microscopic Study. — In the 
celloidin method use different strengths of ethyl alcohol until absolute 
alcohol is reached, then transfer in turn to equal parts absolute alcohol 
and ether; thin celloidin; and thick celloidin. The paraffin method 
is given on page 320. A rapid method of preparing paraffin sections 
is that described by Henke and Heller. 1 The tissues are placed in 
twenty-five volumes of pure acetone, which substance boils at 56°C, 
for thirty minutes to one and one-half hours, depending on their 
size. They are then transferred to melted paraffin at a temperature of 
52 ° C. to 56 C. for an hour or so, and then embedded. If time 
permits, the tissues are to be first hardened in formalin. 

Preservation of Macroscopic Specimens. — If for any reason 
it be desirable to keep specimens for a short time (up to seven to ten 
days ) , as for class demonstrations, they should be kept moist by being 
wrapped in cloths wet with five per cent, formalin solution, covered 
with wax paper, and placed on ice in a covered slop-pail or ice-cream 
freezer. / 

General Considerations. — Washing. — If alcohol be used as the 
preserving solution, blood and other impurities may be removed by 
a thorough washing with water. In other cases the parts should be 
carefully sponged with the preservative to be employed. 

Cavities should be distended with tow or absorbent cotton. The 
lungs should be placed in a jar and the jar filled by pouring the fluid 
through the trachea. Mucous and serous membranes should be pro- 
tected from the distortion caused by shrinkage by being pinned out 
on cork or on wood which will impart no color on soaking. A more 
elegant method is to sew the membranes over the edges of frames 

1 Zentralbl. f. allg. Path., vol. xvi, p. 3. 



PRESERVATION OF TISSUES 377 

made of glass rods. The secreting surfaces of these membranes should 
always be uppermost. 

Compression of any part of the specimen should be avoided by 
the use of a soft cushion of absorbent cotton placed in the bottom 
of the jar. Jars made especially for museum preparations are prefer- 
able, but if necessary they may be replaced by such as are used by 
grocers and druggists for candy, etc. 

Preserving Fluids. — Alcohol is a convenient and efficient agent. 
It preserves form relationships very well, as in tumors, typhoid ulcers, 
invagination of the intestine, etc. ; but it destroys all contrasts in 
a pathologic organ, such as a diseased lung or kidney, and makes 
recognition of the lesion very difficult. It bleaches the tissues and 
causes much shrinkage, so that natural appearances are not retained. 
The specimen is to be washed in water, then immersed in 60 per cent, 
alcohol (which is changed every day until it remains clear), and finally 
kept in 80 per cent, alcohol. To preserve the natural appearance of 
tissues, formalin followed by alcohol is used, and the specimen is 
finally placed in glycerin solution containing some salt of acetic acid, 
usually potassium. Formalin converts the haemoglobin into methaemo- 
globin and a brown color is developed ; alcohol changes the methsemo- 
globin into a red pigment, so that the flesh-color is restored. The 
tissues are so thoroughly hardened that they may be kept in the 
glycerin solution without being thereby softened. The principles 
involved are simple, but their application requires experience and 
ingenuity. All tissues do not respond equally to the treatment, and 
to retain some color peculiar to a certain pathologic condition — such 
as prevails in icterus, for example — requires careful management. 
There are various formulae and different methods of applying them, 
but the two following are perhaps as simple and useful as any. It 
must always be remembered that if the tissues are placed in too strong 
formalin, or remain too long even in a weak solution, the alcohol will 
fail to transform the brown or gray pigment back into red. 

1. Place the fresh organ or a segment as large as the hand for 
from twenty- four to forty-eight hours in one of the following solu- 
tions. 

Kaiserling fluid : 

Formalin 200 c.c. 

Water 1000 c.c. 

Potassium nitrate 15 grammes. 

Potassium acetate 30 grammes. 



378 POST-MORTEM EXAMINATIONS 

Melnikow-Raswedenkow : 

Formalin 10. parts. 

Sodium acetate 3. parts. 

Potassium chlorate 0.5 part. 

Distilled water 100. parts. 

It is well to wrap the specimen in wadding and pour the fluid over 
it. The wadding protects the organ from distortion due to com- 
pression. If the organs are very thick, incise them or inject the blood- 
vessels, ureters, etc., with the fluid. This should be done very gently, 
in order not to wash out the blood. As formalin is injurious to the 
respiratory tract and the skin, it is well when using it to wear rubber 
gloves and to keep the jars covered. 

2. After two days place the specimen in 60 per cent, alcohol, first 
removing the wadding. Two or three days later change to 80 per 
cent, alcohol, then to 90 or 93 per cent. 

3. The specimen is finally placed in the preserving fluid : 

Glycerin 400 grammes. 

Potassium acetate 200 grammes. 

Water 2000 grammes. 

The solutions may be used several times, but a fresh preserving 
fluid is better, and it is even advisable to change it occasionally. 

Pick adds at once to the formalin solution 5 per cent, of Carlsbad 
salts, which prevents the formation of acid hsematin, while Marpmann 
uses fluorsodium both in the formalin solution and in the glycerin. The 
use of ten parts of an 0.8 per cent, salt solution with one part of the 
40 volume strength formalin is also recommended. 

Another method of preserving the natural color of specimens is as 
follows : * One-half of the capacity of a metal box is filled with a con- 
centrated solution of ammonium sulphate, an excess of the crystals 
being left at the bottom of the tank. Above the crystals is arranged 
a grating upon which the specimens to be acted upon are placed. At 
the bottom of the box is a small opening through which carbon dioxid 
or ordinary illuminating gas is constantly passed, thus permitting it 
to bubble up through the fluid in the box. Another tube at the top 
of the box is fitted with a burner so as to burn off the escaping 
illuminating gas. The specimens which remain in the solution under 
the action of the carbonic-acid gas and ammonium sulphate for from 

1 Claudius, Virchow's Arch., 1903, vol. clxxiv, no. 1, p. 103. 



PRESERVATION OF TISSUES 379 

forty-eight to seventy-two hours retain their color for a long while, if 
preserved in this solution. 

After the tissues have been prepared for preservation, it is often 
desirable to embed them in gelatin. For this purpose Watters 1 pre- 
pares the gelatin solution by dissolving 100 grammes each of gelatin 
and potassium acetate in 200 cubic centimetres of glycerin and 
1000 cubic centimetres of water. After standing for twenty- four 
hours the mixture is rendered acid by acetic acid and clarified by heat- 
ing with the white of an tgg. It is then filtered and formalin or thymol 
added. Very attractive mounts may be made in suitable cases by 
using Petri dishes for the containers. 

Littlejohn 2 recommends that fresh specimens or those preserved 
by any well-known method be kept in glass jars made air-tight by 
sealing their covers with gold size and putty. The one objection to 
this method is the vapor which collects in the jars. To avoid this the 
preparations are soaked for several weeks in glycerin and water and 
afterwards placed on wool to which some formalin glycerin is added. 
Perfectly washed stomachs from cases of poisoning, such as carbolic 
acid and the corrosive acids, require no preservative whatever, and 
when thus prepared retain their natural coloring for years. 

The August 13, 1904, issue of the Journal of the American 
Medical Association contains two excellent articles on the permanent 
preservation of specimens, one being by Coplin, on " The Permanent 
Preservation of Anatomic, Embryologic, Pathologic, and Bacteriologic 
Specimens," and the other by Herring, on " Clay Modelling in the 
Study of Anatomy." 

Injected Specimens. — Most beautiful and permanent specimens 
may be made by injecting various colored materials, such preparations 
giving especial opportunity for the study of the arterial and venous 
circulation. Thus, in the case of the liver, if the cystic duct, portal 
vein, hepatic artery, and hepatic veins be injected with four different 
colored solutions, the distribution of the various vessels may be shown 
to perfection. The microscopic study of these cases may be made later 
on. The writer has a fine specimen in his cabinet of the Trichina 
spiralis in the tongue of a cat in which the arterial circulation has 
been injected with carmin. Entwining capillaries surrounding the 
capsule are well brought out. If a warm injecting fluid be desired, 

1 Medical Notes and Queries, June, 1905, p. 81. 

3 Journal of Pathology and Bacteriology, September, 1902, p. 369. 



380 POST-MORTEM EXAMINATIONS 

that of Robin may be recommended. It consists of gelatin one part 
and seven to ten parts of water, heated on a water-bath, to which two 
per cent, of chloral hydrate is added to prevent the formation of 
mould. Any dye may be used to color this solution. For a red color 
take thirty-one centigrammes of carmin, moistened with water, and then 
dissolved in five or six drops of ammonia; fifteen grammes of glycerin 
are then added. This is then mixed with fifteen grammes of glycerin 
to which eight to ten drops of concentrated acetic acid have been 
added and the whole diluted with 

Glycerin 15.0 grammes. 

Alcohol 7.5 grammes. 

Distilled water 22.5 grammes. 

Fischer injects milk and hardens in 

Formalin 75 parts. 

Concentrated acetic acid 15 parts. 

Water 1000 parts. 

Frozen sections are prepared and stained with Sudan III or 
Scharlach R. 

1. Sulphate of iron 0.62 part. 

Distilled water 30.00 parts. 

2. Red potassium f errocyanid 2.00 parts. 

Distilled water 30.00 parts. 

Slowly mix and shake, then when of an opalescent blue color, add 

3. Distilled water 60.00 parts. 

Glycerin 30.00 parts. 

Alcohol 30.00 parts. 

Beale's Prussian blue may be used, and is prepared as follows : 

Glycerin 32.0 parts. 

Alcohol (50 per cent.) 32.0 parts. 

Potassium f errocyanid 0.75 part. 

Tinct. of perchlorid of iron 4.0 parts. 

Distilled water 128.0 parts. 

A practical article on the fixation of tissues by injection into the 
arteries is that by Myers, in the Johns Hopkins Hospital Bulletin, 
February, 1905, p. 66. 

The Johns Hopkins Modification of Schultze's Clearing 
Method. 1 — In making the injection into an embryo or part under 

1 Eben C. Hill, Johns Hopkins Hospital Bulletin, April, 1906, p. in. 



PRESERVATION OF TISSUES 381 

investigation, commercial India ink is diluted to one-third of its 
strength, the injections of small embryos being carried on in warm 
water with the membranes still intact. Thus, in a study of the lym- 
phatics of the small intestine the injecting fluid is inserted in the tho- 
racic duct and into the mesentery; for the respiratory tract, the 
trachea is employed; for the bile capillaries of the liver, the stomach; 
for the uriniferous tubules of the kidney and the Wolffian body, the 
urinary bladder is employed ; and for the venous or arterial circulation 
of the placenta, the umbilical arteries or vein. After the injections 
have been completed all unnecessary tissues surrounding the parts 
under investigation are removed and the specimens are placed in 
an abundant supply of 95 per cent, alcohol until they have become 
completely shrivelled. This will take from three to seven days, 
depending upon their size. After the specimens have become suffi- 
ciently shrivelled they are immersed in a one per cent, potassium- 
hydroxid solution until they appear transparent, which will be in 
from four to forty-eight hours. From this medium they are trans- 
ferred to twenty per cent, glycerin, in which clearing continues and a 
certain amount of hardening occurs, rendering the tissues firm enough 
to permit of dissection. Should the specimens be as transparent as 
is desired they may then be transferred from time to time to higher 
percentages of glycerin, till at last they are permanently stored in pure 
glycerin. Should they not be clear enough, they are placed in equal 
parts of a one per cent, potassium-hydroxid solution and fifty per 
cent, ammonium hydroxid for from five to seventy-two hours. They 
are then placed in twenty per cent, glycerin for forty-eight hours or 
more, the glycerin being increased in strength as before. By follow- 
ing this method, the systems of bones, cartilages, arteries, veins, lym- 
phatics, and various ducts can be demonstrated with a transparent 
embryo or with large sections of adult tissue without any distortion 
of the structures. Bardeen has devised a method by which specimens 
may be mounted upon glass slides and placed in any desired position 
in jars of glycerin. In this method the specimens are removed from 
pure glycerin, wiped, and quickly washed. They are then placed in a 
little thick gelatin solution and are laid upon a warm glass slide in the 
desired position. As soon as the gelatin is hardened, the specimens 
are returned to the pure glycerin without any danger of their 
coming off. 



CHAPTER XXIII 

BACTERIOLOGIC INVESTIGATIONS 

Although it is well known that a bacteriologic investigation is 
often a most important factor in the ultimate value of a post-mortem 
examination, such an investigation is frequently neglected because of 
the lack of facilities or of knowledge of the technic. 1 This ought not 
so to be. In the first place, the cost of equipment, as in post-mortem 
sets, is very largely determined by the conveniences, rather than by the 
necessities. The outfit mentioned on page 41 can be kept always in 
readiness, while the culture-tubes may be obtained quickly and at 
reasonable rates from the larger pharmacal manufacturing companies 
and their agencies. In the second place, the technic is not so compli- 
cated as to require more skill, except in the finer manipulations and 
diagnoses, than should be expected from an educated physician. As 
time goes on, the general practitioner who is not within easy reach of 
a pathologic laboratory or of a board of health will be more and more 
expected to be sufficiently equipped with apparatus and adequately 
trained to make cultures and even inoculations for diagnostic purposes. 
Of course, it is impossible under such circumstances to do the work 
of well-endowed laboratories and skilled bacteriologists, but the mate- 
rial may at least be studied until the time arrives for placing it in 
the hands of those devoting their especial attention to the technic of 
bacteriologic investigations. 

Collection of Material for Microscopic Observations and 
for Culture Purposes. — The important factor in the technic of a 
bacteriologic examination is that all instruments shall be scrupulously 
clean and absolutely sterile, and all sources of contamination carefully 
guarded against in every possible manner. The fluid contents and 
accumulations in abscess and serous cavities, especially meningeal, peri- 
cardial, peritoneal, and pleural, the blood, endocardial vegetations, 
ulcerated areas, and the cut surfaces of solid organs may present foci 
of bacterial invasion which are at once examined by " smear prepara- 

1 Simmonds (Vir chow's Arch., vol. clxxv, no. 3, p. 418) believes, after making 
routine bacteriologic examinations in 1200 cases, that this procedure may sometimes 
give the only definite knowledge concerning the cause of death. 

382 



BACTERIOLOGIC INVESTIGATIONS 383 

tions," and later on by cultures and by animal inoculations, should such 
be deemed necessary. It is important to obtain material as fresh as 
possible and in sufficient amount to permit of a thorough examination. 
Canon 1 states that there is danger of the migration of organisms 
within the cadaver during the first thirty-six hours, even if it be 
properly cared for. Should an early examination be wanted, one of 
the veins of an arm may be exposed shortly after death and the blood 
thus obtained. The method so frequently employed of taking up a 
small quantity of the blood with the platinum loop often gives negative 
results, especially for culture purposes. Bulbs blown in ordinary glass 
tubing furnish one of the most satisfactory means for the securing of 
fluids during an autopsy. They may be purchased in supply houses 
or prepared as follows : A piece of thick tubing is chosen, measuring 
about nine inches in length. The lower portion of the tube is drawn to 
a point and sealed. About three inches from this end, the glass is 
heated to a white heat, the tube being turned all the time and not 
allowed to bend. The open end is now blown into until a bulb about 
one inch in diameter is produced in the heated portion of the glass. 
The upper part is now closed by heat, or the opening preferably is 
filled with a small plug of cotton, and then the whole is sterilized by 
dry heat. When the bulb is wanted for use, the capillary end is broken 
off, and, after aspiration of the fluid, immediately sealed by drawing 
it to a point again. The end previously filled with cotton is also 
melted until it closes. In these hermetically sealed bulbs the material 
may be kept securely until the autopsy is completed, and then be taken 
to a suitable place for such further examination as may be necessary. 
An ordinary 5 to 10 c.c. pipette sterilized and securely wrapped in 
cotton may also be used for this purpose. The end of the pipette is 
placed in the fluid and suction is made through a clean piece of rubber 
tubing, or the pipette is fitted with a suction cap or bulb. Both ends 
are then sealed with the flame. By either of these methods sufficient 
material may be obtained for making differential staining tests and 
also for the inoculation of cultures or of animals. Solid material may 
be removed from the interior of an organ by means of a small spear 
made for this purpose, which has an eye in which some tissue is 
retained as the spear is withdrawn. 

Smear Preparations. — Smears which are to be examined during 

1 Deutsche Zeitschrift f. Chirurgic, 1901, vol. lxi, nos. 1 and 2, p. 93. 



384 POST-MORTEM EXAMINATIONS 

the autopsy may be easily and quickly made, as there is not the same 
risk of contamination that there is in obtaining fluids and solids to be 
used for inoculation. They are prepared in the following manner : A 
number of carefully cleaned and dried cover-slips and slides are placed 
in readiness. 1 A platinum loop for fluids, or the spear-headed spatula 
for solids, is then sterilized by heating to a red glow in an alcohol flame 
or in the upper (hottest) part of a Bunsen burner. If the liquid to be 
examined is of considerable consistency, like pus, blood, and exudates, 
a drop of it is placed by the aid of the sterilized loop upon a clean 
cover-slip. The cover-slip is then dropped upon a slide one-third of its 
length from one end, and, after the drop has spread, the cover-slip is 
drawn gently by means of forceps across the remaining two-thirds of 
the slide. The slide is much easier to manipulate than two cover-slips 
prepared by drawing one over the other, is not so easily broken, and 
gives a larger field for future study. Fluids may also be spread zigzag 
upon the slide or cover-slip with the platinum loop or with a small 
pipette, the latter being preferable whenever the fluid is very thin, 
making large amounts necessary. Should the material not be suffi- 
ciently fluid to make a satisfactory smear preparation, a little distilled 
water or physiologic salt solution may be put on the glass before per- 
forming the above manipulations. If preferred, a solid organ may be 
incised with a scalpel sterilized by heat, and the cover-slip or slide 
applied directly to the freshly cut surface. The material thus collected 
may then be smeared over the glass with the platinum loop. The 
" smear" being dried with very little heat, — or, better, with none, — 
now requires only " fixing" on the glass. This is done by the routine 
method of passing it three times through a flame, with the smeared 
surface upward to avoid burning the material. If a cover-glass is used, 
the passage through the flame is made more quickly than when the 
thicker glass slide is employed. In " fixing," very great care must be 
used to avoid the application of too high a temperature, — shown by a 
brownish coloration, — which would seriously distort the bacteria, espe- 
cially if the film had not been thoroughly dried previously. By the 
heat applied in this way, the albuminous organic matter is dried or 
coagulated, and the bacteria and cellular elements are thus caused to 



1 It is well to use new cover-slips which have been cleansed in strong nitric 
acid, washed in distilled water, and kept in alcohol to which a few drops of ammonia 
have been added. When wanted for use, they should be wiped dry between the 
fingers with Chinese tissue paper or with a clean cloth. 



PLATE V.— BACTERIOLOGIC CHART. 

No. i. Gonococcus : smear preparation from urethral pus; stain, methylene blue. No. 2. Pneumo- 
coccus : smear preparation from sputum; Welch's acetic acid stain. No. 3. Streptococcus pyogenes : 
smear preparation from pus ; stain, methylene blue. No. 4. Micobacterium tuberculosis: smear prepa- 
ration from sputum ; stain, Ziehl's method. No. 5. Vibrio cholerce : stain, carbol fuchsin. No. 6. Cory- 
nebacterium diphtherice : stain, Lomer's method; lower portion of figure shows the polar staining of 
Neisser's granules. No. 7. Bacterium typhosum, showing flagella ; stain, van Ermenghem's method. 
No. 8. Bacterium dysenteries : stain, methylene blue. No. 9. Achorion Schonleinii (favus fungus), with 
conidia and mycelia : stain, Bismarck brown. No. 10. Bacillus anthracis : smear preparation from spleen 
of a mouse ; stain, gentian violet ; to bring out the spores stain with Ziehl's solution. No. 11. Bacillus 
aerogenes capsulatus : smear preparation from spleen; stain, gentian violet. No. 12. Yeast cells with 
buds and ascospores, starch cell in lower right-hand corner; stain, weak Lugol's (Gram's) solution. 







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BACTERIOLOGIC INVESTIGATIONS 385 

adhere so firmly to the glass surface that they will not be washed off 
by future manipulations. Such preparations may be kept for a consid- 
erable length of time before being stained, and can be safely and easily 
protected by gumming the clean surface of a piece of card-board cut to 
the size of the ordinary glass slide, on which also may be written all 
necessary data. The cards may then be packed in a slide-box or in an 
ordinary pill-box, care being exercised that the films do not come in 
contact with anything that will be liable to rub or scratch them. 
Another method of keeping slides apart is to lay short pieces of match- 
sticks across the ends of one of them placed face up and then to put 
another slide face down on the match-sticks and bind the slides firmly 
together with a gum elastic band placed around them lengthwise. 

Selection of Culture-Media. — A diagnosis made from the 
study of smear preparations must often be corroborated by cultures, 
though the previous study of the smear has frequently offered valuable 
suggestions as to the particular kind of culture-media to employ in the 
case under observation. For instance, if a Diplococcus be found as the 
prevailing organism, a special medium will be necessary, as the three 
most common varieties of the Diplococcus — viz., the Pneumo coccus, 
the Gonococcus, and the Diplococcus intracellular is — grow poorly and 
in many cases not at all upon ordinary media. Or the microbe may be 
one that can be most easily isolated by immediate inoculation into an 
animal, as in the case of the tubercle bacterium and the Pneumo coccus. 
Again, existing conditions of the organs and tissues may point to infec- 
tion by an anaerobic organism, as the gas bacterium, and in such cases 
a medium and a method suitable for anaerobic growth — namely, the 
exclusion of oxygen — must be employed. Wallis * drops a little of the 
melted media upon a cover-glass, places a hair suspected of contain- 
ing the parasite upon it, puts the cover in a moist chamber, and incu- 
bates at the room temperature. The slide is examined in the usual 
manner. 

The following list, prepared chiefly according to the nomenclature 
adopted in the third German edition of Lehmann and Neumann's 
Bakteriologische Diagnostik, gives the best media for the isolation of 
the pathogenic micro-organisms most commonly found post mortem, 
those having spores being called bacilli, while those which have none 
are designated bacteria. (Plate V.) 

1 Jr. Amer. Med. Assoc, August 20, 1904, p. 531. 
25 



386 POST-MORTEM EXAMINATIONS 

Bacillus anthracis. All ordinary media, especially agar. White or house mouse. 
The Bacillus subtilis is motile, while this organism is not, though very similar 
morphologically. (Plate V, no. 10.) 

Bacillus cedematis maligni. Anaerobic culture methods. Ordinary media with the 
addition of glucose. 

Bacillus tctani. Anaerobic culture methods. Grows in long threads on ordinary 
media with the addition of glucose. Spores; motile; flagellated. 

Bacterium aerogenes capsulatum. Anaerobic culture methods. Ordinary media with 
addition of glucose. (Plate V, no. n.) 

Bacterium coli commune. Glucose agar-agar shows gas formation, thus distinguish- 
ing it from the typhoid germ. It also contains fewer flagella than the latter. 
Agglutinates. Milk is coagulated. Marked indol production in peptone 
solution. 

Bacterium dysenteric? (Shiga). Plain agar-agar. A flagellated organism not stained 
by Gram's method. Agglutinates. Milk not coagulated, nor are sugars fer- 
mented. Does not form indol in peptone solution. (Plate V, no. 8.) 

Bacterium enteritidis. The bacterium of hog cholera may produce gastric disturb- 
ances in man after eating contaminated meat. It is probably a modified form of 
the Bacterium coli. 

Bacterium influenza. Agar-agar smeared with human blood or glycerin agar. 

Bacterium paratyphosum. Grows on ordinary media. This organism is classified 
between the typhoid and the colon bacterium. Agglutinates, but may have to 
use several cultures before securing the proper one. 

Bacterium pestis. All ordinary media. 

Bacterium pneumonice. A facultative organism growing on all ordinary media. 

Bacterium pyocyaneum. Plain agar-agar. 

Bacterium rhino scleromatis. Probably the same as the B. pneumonice. 

Bacterium septiccemice hcemorrhagicum. The bacillus of chicken cholera. Should be 
studied with wine, milk, and glucose media. 

Bacterium typhi murium. The bacillus of mouse septicaemia is similar to the bac- 
terium of hog cholera and the paratyphoid. 

Bacterium typhosum (Eberth's bacillus). Hiss's gelatin-agar medium. Can grow 
on all media. Not stained by Gram's method. Flagellated organism. Cultures 
best obtained from blood, spleen, and urine. Agglutinates. Does not coagulate 
milk or form indol in peptone solution. In dextrose, lactose, and saccharose 
bouillon very little acid is produced and no gas. (Plate V, no. 7.) 

Bacterium vulgare or proteum. Non-motile ; stains with Gram. It is a facultative, 
sugar-decomposing, and agglutinative organism. 

Cory neb act erium diphtherice. Blood-serum bouillon. A guinea-pig may be inocu- 
lated to see if the organism is virulent, thus distinguishing it from the so-called 
pseudodiphtheria bacillus. Non-motile. The Bacillus xerosis is, in all proba- 
bility, this organism. (Plate V, no. 6.) 

C orynebacterium mallei. Optional anaerobic. Guinea-pig is to be inoculated in the 
testicle. Not stained by Gram's method. 

C orynebacterium xerosis. See C orynebacterium diphtherice. 

Diplococcus intracellular is meningitidis. Careful search will show this organism 
in the blood in twenty-five per cent, of all cases. Rarely found by culture 
post mortem. Ascitic fluid. 

Gonococcus or Micrococcus gonorrhoea. Ascites-glycerin agar and hydrocele agar 
give fairly good results. Gonorrhceal ophthalmia may be produced in rabbits 
by inoculating the mucosa of the eye. Does not stain by Gram. (Plate V, no. 1.) 



BACTERIOLOGIC INVESTIGATIONS 



3«7 



Micrococcus or Streptococcus intracellular is. Glycerin agar or agar smeared with 
blood gives the best results. Loffler's blood-serum and potato may be used. 
The coccus is found in the pus of the brain, cord, and ear, the nasal mucus, the 
sputum, and the urine of those affected with the disease. A large quantity of 
the exudate should be used, for many of the bacteria present are dead. 

Micrococcus melitensis. Glycerin agar or potato. Grows as a bacterium. Material 
to be taken from the cervical or inguinal glands and from the lungs. Agglu- 
tinates. 

Micrococcus or Staphylococcus pyogenes aureus. Grows luxuriantly upon all 
media in general use. The M. citreus and the M. albus are but varieties of this 
genus. Suppuration is usually circumscribed. 

Mycobacterium leprce. It is innocuous for animals. It is grown upon glycerin agar- 
agar with great difficulty. Acid resisting. 

Mycobacterium tuberculosis. Glycerin agar-agar is the best medium. Confirm diag- 
nosis by subcutaneous inoculation of guinea-pig. Probably agglutinates under 
proper conditions. O. von Schron x has recently announced, through his assist- 
ant Galbo (Riforma medica, 1904, vol. xx, no. 29, p. 800), the discovery of the 
phthisiogenic micro-organism in the caseous masses of tuberculous lungs. Von 
Schron considers tuberculosis and phthisis as two distinct diseases, the former 
preceding the latter in the formation' of cavities ; the walls being formed by 
three strata, the results of evolution, involution, and degeneration of the 
parasite, the specific crystals being prisms, and not rhombs, as in the case of the 
tubercle bacillus. (Plate V, no. 4.) 

Pneumococcus or Streptococcus lanceolatus. Ascites agar and ascites-glycerin agar 
are the best media. The best method is to inoculate a mouse or rabbit sub- 
cutaneously with the rusty sputum or with pus. A mouse dies in from twelve 
to twenty-four hours, and its blood contains large numbers of the Diplococcus. 
pneumonia, showing the capsule most strikingly; a rabbit dies in from two to* 
five days. The agglutination of Pneumococci by a long, complicated procedure 
may be obtained with the serum of immunized animals and pneumonic patients. 
(Plate V, no. 2.) 

Sarcince. Best cultivated in bouillon or hay decoction, displaying fine shades of 
various colors. 

Spirochceta Obermeieri. No culture method known. Monkeys show disease after 
inoculation. 

Spirochceta pallida. See Treponema pallidum. 

Streptococcus pyogenes. This organism is most easily recognized by smear prepara- 
tions and grows well upon all media in common use. It produces erysipelas as 
well as pus. Suppuration is usually wide-spread ; but may be circumscribed 
in an immune animal. (Plate V, no. 3.) 

Streptothrix actinomyces. Grows well upon agar-agar and blood serum. Does not 
stain with Gram's solution. 

Treponema pallidum. 2 After the discovery of the Cytorrhyctes luis by Siegel, 
Schaudinn and Hoffmann announced the presence in syphilitic lesions of the 
Spirochceta pallida and 5. refringens. The vS. pallida, or, as better named, 

1 Medico-legal Jr., March-June, 1905. 

2 The meaning of which is " a pale, turning thread." A recent and easily 
accessible account (with literature) of this organism is by Pfender, Amer. Med., 
March 10, 1906, p. 350. For an excellent illustration see Deut. med. Wchnschr., 
1905, vol. xxxi, no. 42. 



388 POST-MORTEM EXAMINATIONS 

the Treponema pallidum, is a delicate, actively motile, faintly refractile, long, 
thread-like, spiral, flagellated protozoon, tapering at both extremities and 
terminating in pointed ends. The ultraviolet microscope has demonstrated a 
nucleus in a number of specimens, and specimens presenting six to eight spirals 
are probably two or more joined individuals. The thickness rarely reaches 
a quarter of a micron. 
Vibrio cholerce. Glycerin agar. All ordinary media, especially gelatin at 22° C. 
Usually a single flagellum. Agglutinates. (Plate V, no. 5.) 

The following diseases are due to specific organisms or protozoa, 
but the etiologic factor as such, though described, has not yet been 
definitely accepted as the cause of the affection, symbiosis possibly 
playing an important part in the etiology of some of them : Acro- 
dynia, or epidemic erythema; poliomyelitis; beriberi (possibly an 
arsenical neuritis) ; cancer; chancroid; chicken-pox; chorea; cow-pox; 
foot-and-mouth disease; measles (bacillus of Canon and of Czajkow- 
ski) ; miliary fever; mumps; pellagra; rabies; rheumatism; rose rash; 
scarlet fever; smallpox; typhus; whooping-cough (Bacillus pertussis, 
B. minutissimus sputi, and B. tussis convulsive?) ; yellow fever (Bacil- 
lus X and B. icteroides). 

Inoculating Culture-Media. — Test-tubes containing any of the 
solid or liquid media may be inoculated at the place where the autopsy 
is performed when it is not so far from the laboratory as to endanger 
the growth of the culture by exposure to extremes of temperature. 
Sufficient heat is secured, however, by placing the tubes after inocula- 
tion, securely wrapped, in an inside coat-pocket. 

The first step in inoculation of the tube containing the medium is to 
" flame" the cotton plug in its mouth, for the purpose of killing any 
bacteria that may have fallen upon the cotton-wool. During inocula- 
tion the tube is held as nearly in the horizontal position as is consistent 
with safety to its contents, so as to diminish the risk of contamination 
of the medium by the falling into the tube of the bacteria from the 
air. Thus, should the tube contain a solid medium, such as blood- 
serum, it may even be inverted before inoculation. The platinum 
wire, held in the right hand, is now sterilized by heat and cooled, 
while the cotton plug is removed from the test-tube by a corkscrew 
motion and held, inner part outward, between the middle and index- 
fingers of the left hand in such a manner that it does not come in 
contact with any portion of the hand or other extraneous object. With 
the tip of the platinum wire a small portion of the substance to be 
inoculated is now placed on the surface of the medium ; if this surface 



BACTERIOLOGIC INVESTIGATIONS 389 

is slanting, the fluid is rubbed gently over it, or drawn in a line across 
it, thus making a " smear" and " stroke" culture, while the needle is 
thrust deep down into the medium if a " stab" culture is to be made. 
The ose is then withdrawn, the cotton plug reinserted, the needle 
sterilized, and the tube labelled and put in a warm spot until it can 
be placed in the incubator. 

If the culture is to be made from the surface of a solid organ, the 
method is the same, except that the organ is first seared with a hot 
knife and next incised with a sharp, sterile knife. Should the same 
knife be used for both purposes, it is wise, as a precautionary measure, 
to sterilize the instrument again before plunging it deep into the 
tissue. In some instances, in which many of the bacteria are dead, 
much larger amounts of the infectious material must be used for 
inoculation, and then the entire contents of a bulb or pipette may be 
introduced into a flask of bouillon or other medium. 

Cultivation of the Inoculated Tubes. — The pathogenic bac- 
teria grow best at about the body-temperature, and so all cultures, 
except gelatin plates, are placed in an incubator during growth. If 
anaerobic methods are indicated, the tubes must be prepared for the 
exclusion of oxygen. Wright has devised a simple and satisfactory 
method, which is a modification of Buchner's two-tube method and 
does not require any special apparatus. Its principle is based upon the 
absorption of the oxygen in the air by pyrogallic acid and caustic 
soda, leaving an atmosphere of nitrogen. A single tube is inoculated 
in the usual way. The cotton plugs are then cut off even with the 
mouth of the tube and pushed in to the distance of three or four centi- 
metres. One cubic centimetre of a ten per cent, aqueous solution of 
pyrogallic acid is then dropped upon the cotton plug and followed by 
the same amount of a decinormal solution of caustic soda. The mouth 
of the tube is then quickly closed with a close-fitting rubber stopper 
and the culture-tube is placed in the incubator. Hirshberg 1 has slightly 
modified this method by mixing the pyrogallic acid and sodium nitrate 
directly with a second tube of melted agar and then pouring this over 
a deep stab culture of the inoculated agar tube. Hessee's method of 
turning sterile oil into a test-tube in which a deep stab culture has 
been inoculated is often convenient. 

Preparation of the Inoculum. — The materials used for inocu- 
lation are either the pathologic products — namely, the secretions and 

1 Jr. Amer. Med. Assoc, May 21, 1904, p. 1355. 



390 



POST-MORTEM EXAMINATIONS 



excretions and the solid tissues, which have been collected in sterile 
bulbs or pipettes from the different cavities of the body and from the 
organs — or cultures which have been obtained by the inoculation of 
these products upon culture-media. If the material is in a sterile bulb, 
break off the end of the tube with sterile forceps and expel the contents, 
by the application of heat to the bulb, — the warmth of the hand is 
usually sufficient, — into a sterile capsule (a small Petri dish with a 
tightly-fitting ground-glass cover). The injecting syringe is then 
filled from the capsule. If the fluid is too thick, it may be diluted 
with a sterile salt solution. Cultures of bacteria may be prepared in 
the same manner, and solid tissues may be emulsified in a salt solution. 

Inoculation of Animals. — The animal to be used for inoculation 
should be carefully selected from those commonly employed for experi- 
mentation with reference to its own health and to the species required, 
as indicated by the microscopic examination of the smear preparation. 
The animals most used for this purpose are the rabbit, guinea-pig, 
white mouse, rat, pigeon, and domestic fowl. These differ in their 
susceptibility to the different pathogenic bacteria infesting man, and 
negative results are sometimes seen because animals are used which 
are unsuited to the disease under investigation. Thus, in cases of sus- 
pected syphilis the baboon, ape, or monkey must be employed, and in 
typhoid inoculations the animal must be specially medicated so as to 
render it susceptible to the bacterium causing the disease. 

The animal should be weighed and the rectal temperature (Fig. 
1 83 ) taken before inoculation, and both weight and temperature should 
be recorded at a certain time each day during the period of observation. 
The same rules apply as to asepsis in the inoculation and to avoidance 
of contamination of the inoculum as are required in a surgical opera- 
tion. The instruments, similar to those used by surgeons, are sterilized 
by boiling, owing to the difficulty of removing chemic disinfectants 
which even in traces might inhibit the growth of bacteria and so 
vitiate the experiment. An ordinary hypodermic syringe may be em- 
ployed, but one should be selected that can easily be cleansed and dis- 
infected. Koch's inoculation syringe is much used; many, however, 
prefer Roux's or some modification of it. The glass and metal por- 
tions of the syringes may be sterilized by boiling, but the washers are 
injured by frequent boiling and should be disinfected by a five per cent, 
solution of carbolic acid, followed by careful washing in sterile water. 

The site of inoculation varies with the different animals and also 



Or? f 4 

S-3 







cr T3 
2. o 
0"? <2 





Fig. 185.— Method of performing peritoneal injection in a rabbit. 




Fig. 186. — Ear method of inoculating a rabbit. 




Fig. 187. — Post-mortem examination of guinea-pig, made in Ravenel pan. Near the 
four corners, but not shown in the illustration, are hooks upon which the chains are 
fastened in order to hold the animal in position. 




Fig. 188. — Post-mortem examination of a rabbit upon wooden post- 
mortem board. 



BACTERIOLOGIC INVESTIGATIONS 391 

with the different varieties of the pathogenic bacteria. The usual 
methods are the subcutaneous, the intraperitoneal, and the intravenous. 
In small animals like the mouse the last two methods are rarely used, 
although a very small dose, one or two minims, of fluid may be in- 
jected into the peritoneal cavity. Subcutaneous inoculation is com- 
monly practised in the mouse. A fold of skin is pinched up between 
the thumb and forefinger of the left hand, the hypodermic needle 
attached to the barrel of its syringe, filled with the material to be intro- 
duced, is thrust into the ridge of skin until it enters the subcutaneous 
tissue, when the fluid is slowly injected; or a piece of skin is snipped 
with a pair of sharp-pointed scissors, a probe is pushed into the sub- 
cutaneous tissue, making a small pocket, in which a portion of the 
solid inoculum is deposited. (Fig. 184.) The wound may then be 
dressed with gauze and sealed with collodion. 

The intraperitoneal inoculation is made as follows : The animal is 
held by an assistant or secured to a table. A broad area over the 
abdomen is shaved, care being taken not to injure the nipple, and the 
skin is thoroughly disinfected with a two per cent, lysol solution, which 
is washed off with alcohol. The entire thickness of the abdominal 
parietes is then pinched up into a triangular fold, the peritoneal sur- 
faces are slipped one over the other to ascertain that no coil of intestine 
is included in the fold, and the hypodermic needle is passed through 
the fold near its base. The fold is then released, but the syringe is 
held steady. The parietes now flatten out, leaving the needle free in 
the peritoneal cavity. The fluid is then slowly injected. (Fig. 185.) 

Intravenous inoculation is not usually practised in animals smaller 
than a rabbit. In this animal the posterior auricular vein is the one 
selected for the operation. (Fig. 186.) If a guinea-pig should be 
chosen, the jugular vein is selected and an anaesthetic is used, the A. C. 
E. mixture being preferred for general and cocaine for local anaes- 
thesia. The animal is held by an assistant or securely wrapped in a 
towel fastened with pins, the selected ear is grasped by the root and 
stretched forward towards the operator, the dorsum of the ear having 
been previously shaved and cleansed. The syringe is held as one 
holds a pen, and the needle is thrust through the skin and into the 
vein itself, being pointed in the direction of the blood stream. The 
inoculum is then slowly injected and the needle withdrawn. 

In the selection of a site for inoculation the general rule is to inject 
each variety of micro-organism into the kind of tissue which it most 



392 POST-MORTEM EXAMINATIONS 

often infests in man. For instance, if the lymph-glands are the primary 
seat of invasion, the animal should be inoculated in that portion of 
its body which will afford the quickest means of carrying the infectious 
material to the lymphatics; as, in the test for glanders the bacillary 
matter is introduced into the testicle, which contains an abundance of 
these vessels and but a scant blood supply. Or, if the brain and spinal 
cord are most affected by the disease, as in rabies, an intracranial 
inoculation is preferred. Thus, the lesions found during the autopsy 
and the bacteria seen in the microscopic specimens will give a clue 
regarding the most desirable seat for the inoculation. 

Post-Mortem Examination. 1 — The post-mortem examination of 
animals dying from disease produced by experimental inoculation 
should always be made as soon as possible after their death, and not 
later than twelve hours. The animal is fastened on a board, ventral 
surface upward, by nails driven through the extremities, or by being 
tied with string to special contrivances placed at the corners. Its fur 
is then wet with a weak antiseptic liquid, such as a two per cent, lysol or 
a five per cent, carbolic solution, to avoid contamination, to prevent the 
flying off of hairs, and to kill the vermin which are so often present. 

The tray of the sterilizer containing the necessary instruments, 
such as scissors, scalpels, forceps, etc., and the slides, cover-slips, and 
culture-media, are placed where they may be easily reached. Then, 
with sterile forceps and scalpel, the skin of the animal in the middle 
line is incised from the top of the sternum to the pubes, or, if scissors 
be used for this purpose, the reverse order is followed. Two other 
incisions are made at right angles to this line, through the axillae and 
groins. The skin is next reflected in flaps, and may be tacked to the 
board for the sake of security. The seat of inoculation is then in- 
spected, and, if any lesions are visible, the surface is seared and material 
removed for cultures and smears. The surface of the thorax is seared 
and the ribs are divided on each side of the sternum, the chest-plate 
being removed in the usual way. The pericardial sac is burnt through 
with the searing iron or incised with a scalpel. The right ventricle of 
the heart is seared, and into it the pipette is passed and filled with blood 
for the preparation of smears and inoculation of tubes. Through a 



1 The reader is referred to the chapter on comparative postmortems for a fuller 
description of the technic, especially in necropsies on the larger animals, as the cat, 
dog, sheep, cow, and horse. The methods in vogue for performing a bacteriologic 
postmortem are seen in Fig. 187 (guinea-pig) and Fig. 188 (rabbit). 



BACTERIOLOGIC INVESTIGATIONS 393 

seared tract in the middle line of the abdominal wall an incision is 
made and a specimen of the peritoneal fluid collected. A specimen of 
the urine is now saved in the same manner as described for collecting 
the blood. The spleen is excised and placed in a sterile capsule, and 
through its seared surface the spear-headed spatula is plunged and 
twisted around so that the eye is filled with material for microscopic 
and cultural purposes. This process may need to be repeated several 
times. The other organs, as the lungs, liver, kidneys, lymphatic glands, 
etc., are removed in a like manner, and all the cavities of the body 
carefully examined. Specimens of the various tissues may be cut 
into cubes and placed in fixing fluids for future sectioning. Eyre 
suggests that a different knife or separate sterilization is needed for 
cutting each organ. After use the instruments are sterilized and disin- 
fected by boiling. The animal is wrapped in a cloth moistened with 
an antiseptic solution, as pure formalin, and cremated. Every pre- 
caution should be taken to prevent dispersion of the pathogenic bac- 
teria, — as, e.g., by the dropping of cover-glasses, which on becoming 
broken might cause infection later on. Von Szekely found some 
dried-up gelatin cultures of anthrax and of malignant cedema, eighteen 
and one-half years old, to be still virulent to white mice. 



CHAPTER XXIV 



WEIGHTS AND MEASUREMENTS 



A knowledge of the weights and dimensions of the normal and 
pathologic organs of the body is required of all necroscopists. An 
organ should be measured before it is weighed, with the exception 
of the intestine, which is preferably measured after it has been 
opened in its entirety, cleansed, and weighed. Measurements should 
be made as nearly as possible under similar conditions. In measuring 
an organ its length, breadth, and thickness may often be more quickly 
and accurately ascertained by thrusting the steel rule through it than 
in any other manner. In the healthy body size is dependent upon sex, 
age, height, and weight of the subject, while in morbid states it 
differs according to the above conditions and the disease present. 
Some parts are preferably weighed before opening, others after opening, 
and still others both before and after the incisions are completed. 
Letulle advocates the following plan : 



Weigh before opening. 


Weigh after opening. 


Weigh before and after opening. 


Pineal gland. 


Alimentary tract. 


Brain. 


Pituitary body. 


Aorta. 


Liver. 


Spinal cord. 


Bladder. 


Lungs. 


Spleen. 


Glands, including salivary. 


Kidneys. 


Suprarenals. 


Heart. 


Uterus. 


Thymus and thyroid. 


Pancreas. 





Various Systems of Weights and Measurements. — It is cus- 
tomary in this country and in England to give the weights of the 
organs in avoirdupois ounces, 1 their dimensions in inches, and their 
capacity in cubic inches, though the metric system has more to 
commend it and will probably be employed after 1909 in all of the 
Departments of the United States Government in the transaction of 
business requiring the use of weights and measures. The grain is the 
same in both Troy and avoirdupois weights. The ounce avoirdupois 
contains 437.5 grains, or 28.35 grammes; and the ounce Troy, 480 



1 Troy weight is sometimes used and may give rise to much confusion. 
394 



WEIGHTS AND MEASUREMENTS 395 

grains, or 31.1 grammes. To convert grammes into avoirdupois 
ounces divide by 28.35 5 i nt0 Troy ounces, divide by 31.1. To convert 
grammes into grains divide by 0.065. Conversely, to convert ounces 
avoirdupois into grammes multiply by 28.35 ; into Troy ounces, multiply 
by 3 1. 1. To convert grains into grammes multiply by 0.065. A kilo- 
gramme equals 1000 grammes, or 2.2 pounds. A gramme equals 1000 
milligrammes, or 15.432 grains. A litre equals 1000 cubic centi- 
metres, or 61.028 cubic inches, and is equivalent to 2.1 13 American 
pints or 1.76 English pints. A metre equals 1000 millimetres, or 
39.37 inches. A millimetre equals 2V of an inch. A micron equals 
the thousandth part of a millimetre. The following abbreviations are 
employed in this chapter: mm., for millimetre; cm., for centimetre; 
in., for inch; ft., for foot or feet; gm., for gramme; kg., for kilo- 
gramme; lb., for pound; cc, for cubic centimetre; cu. in., for cubic 
inch; gr., for grain; dr., for drachm; oz., for ounce. 

Height and Weight of the Body. — The American Insurance 
standard is as follows : * 

A man of 5 ft. and 1 in. should weigh.... 54.55 kgs. (120 lbs.) 

A man of 5 ft. and 3 in. should weigh.... 59 kgs. (130 lbs.) 

A man of 5 ft. and 6 in. should weigh.... 65 kgs. (143 lbs.) 

A man of 5 ft. and 9 in. should weigh. .. . 70.45 kgs. (155 lbs.) 

A man of 5 ft. and 11 in. should weigh.... 75 kgs. (165 lbs.) 

The average weight of a full-term boy at birth is 3600 gms. (7 lbs., 
15 ozs.) ; that of a girl, 3250 gms. (7 lbs., 2% ozs.). A child may be 
born weighing less than a pound and yet live. The mean length 
of a full-term, sound child is between 50 and 51 cms. (19^ and 
20 ins.), the male being slightly longer than the female. Draper 
considers it important to note if the navel is at the middle of the 
body, as this is the sign of a full-term child. The rule that a child 
has usually attained double its birth weight at the fifth month and 
triple at from the twelfth to the fourteenth month is fairly accurate. 
When a child is two years old, it is about half as tall as it will be when 
fully grown. The greatest recorded weight is that of a man born 
in North Carolina in 1798 who measured 7 ft. 8 ins. (2.338 metres) 
in height and who weighed over 1000 lbs. 2 

Jamin and M uller, of Erlangen, find the specific gravity of the 

1 From Finlayson's Clinical Manual. 

2 Gould and Pyle, Anomalies and Curiosities of Medical Literature, quoted 
from the Medical Press and Circular. 



396 



POST-MORTEM EXAMINATIONS 



living body at eight years of age to be 1.130, and 1.065 after sixty. 
The average for all ages and both sexes is 1.088 in health and 1.074 
in pathologic conditions. In obesity it may be as low as 1.004. Katz x 
has made some interesting chemic analyses of muscle taken from man 
and from the lower animals. The younger the animal, the more 
water will it contain, the cardiac muscle containing the least water. 
Fehling 2 gives the percentage of water in a very young fcetus as 97.5 
per cent.; after birth, 74.7. In the adult it is 58.5 per cent. Horse- 
flesh can be told by its high iodin index and specific blood-test. 

The approximate weights of the organs of the body with their 
percentage in relation to the body-weight are as follows : 



Brain 3 

Heart 

Lungs 

Thymus gland 

Spleen 

Liver 

Pancreas .... 
Kidneys 4 . . . . 
Testicles .... 

Ovaries 

Adrenals .... 

Muscles 

Skeleton 



ADULT 



Grammes 



I4OO 
3OO 

"75 

5 

170 

1600 

200 

300 

48 

H 

10 

30000 

1 1500 



Ounces 



Percentage Grammes 



NEW-BORN 



49. 
IO. 
41. 

O.13 

6. 
57- 

7- 
10.5 

i-5 
0.5 
0-35 
1050. 
400. 



2-37 

0.46 

2. 

0.0086 

0.346 

2.75 

0.346 

0.48 

0.12 

0.04 

0.014 

43-09 

15-35 



385. 
24. 

58- 
10. 

118. 

II. I 

23.6 
0.8 
0.5 

8. 
625. 

445- 



Ounces 



13 



846 
045 

3 
3 
162 

39i 

832 

0282 

0176 

3 

045 

696 



Percentage 



14-34 
I. OO 
2.l6 
0.54 
0.34 
4- 30 
0.41 
0.88 
0.03 
0.18 
0.31 
23.40 
16.17 



Lambion 5 gives the following figures, obtained at the Liege 
Maternity, as to the weight of the placenta in cases of miscarriage: 
The average weight of the placenta at 6 weeks was 20 gms. ( 5 drs. ) ; 
at 90 days, 6j gms. (17% drs.) ; at 120 days, in gms. (28^ drs.) ; 
at 165 days, 262 gms. (67^ drs.) ; and at 235 days, 330 gms. (84% 
drs.). The average weight of the placenta at term is a little over a 
pound (500 gms.). The umbilical cord, at birth, averages 2j gms. 
(7 drs.) in weight and y 2 metre (19 ins.) in length. 



1 Arch. f. d. ges. Physiol, 1896, vol. lxiii, no. 1, p. 1. 

2 Cook, Jr. Amer. Med. Assoc, June 6, 1903, p. 1548. 

3 According to Marchand, the brain's weight at birth is doubled at eight months 
and is trebled at three years of age. 

4 The right being about 5 gms. (77 grs.) heavier. 

5 De la determination de Vage du fcetus d'apres le poids du placenta dans les cas 
de fausse couche, Paris, 1898. 



WEIGHTS AND MEASUREMENTS 397 

Embryos 1 about 1 mm. (-£$ in.) long are about 12 days old; 2.5 
mms. (yg- in.), 14 days old; 4.5 mms. (A in.), 19 days old; 7 
mms. ( T 3 o- in.), 26 days old; 11.5 mms. (f|- in.), 34 days old; 17 mms. 
( 2 /z in.), 41 days old. For all embryos from 1 to 100 mms. long, 
multiply the length of the embryo from the vertex to the breech in 
millimetres by 100 and extract the square root; the result will be 
the age in days. For embryos from 100 to 200 mms. long, measure 
from vertex to breech; this length in millimetres will equal the age 
expressed in days. Or, for the last five lunar months of fetal life, 
if the height expressed in centimetres be divided by 5, the approximate 
age of the child in lunar months will be obtained. For example, if 
the child measures 35 cms., we divide this by 5, and we have 7, which 
is the number of months which, #he child has passed in utero. The 
fetal age of the child in the first five months about equals the square 
root of the height expressed in centimetres. For example, if the height 
is 16 cms., the child is 4 lunar months old. In terms of the English 
system, if the length of the new-born child expressed in inches be 
divided by 2, it will give approximately the number of lunar months 
that the child has passed in utero. 
♦ 

THE SKULL AND ITS CONTENTS. 

Shape. — The form and size of the skull varies. The characteristic 
measurements of the cranium are its length, height, and breadth. The 
cephalic index is the ratio of its length (taken as one hundred units) 
to its' breadth. The altitudinal index is the ratio of its length to its 
height. The accepted horizontal plane is that passing through the 
upper edges of the external auditory meatus and the lower orbital 
margin. 

According to the variations of the cephalic index, we distinguish 
the dolichocephalic (index less^than 75) and the br achy cephalic (index 
more than 80) types. Interrriediate forms are called mesocephalic. 
If the ratio of the breadth to the height is less than 70, the skull is 
platycephalic; if between 70 and 75, or tho cephalic; if above 75, hypsi- 
cephalic. The character of the facial profile is indicated by the facial 
angle of Camper, — namely, the angle between a line on the level of 
the external auditory meatus and the floor of the nasal cavity and a 

1 Mall, Bull. Johns Hopkins Hosp., vol. xiv, no. 143, February, 1903, p. 29; 
abstracted in Medicine, vol. ix, no. 3, 1903, p. 240. 



398 



POST-MORTEM EXAMINATIONS 



line touching the middle of the forehead and the anterior portion of 
the alveolar process of the superior maxilla. If this angle be 80 de- 
grees or more, the skull is called orthognathous; if it is between 80 
degrees and 65 degrees, prognathous (Gegenbaur). 

Pathologic types of skull are due in part to premature synostosis. 
Among them we distinguish the hydrocephalic type (from dropsy of 
the ventricles), the cephalonic (or big head), the microcephalic (or 
small head), the dolichocephalic (or long head), the spheno cephalic 
(or wedge-shaped head, due to compensatory development of the ante- 
rior fontanel), the leptocephalic (or narrow head), the clinocephalic 
(or saddle-shaped head), the trigonocephaly (or triangular head, due 
to narrowing of the frontal bone from fetal synostosis of the frontal 
suture), the br achy cephalic (or short head), the pachy cephalic (in 
which the bones of the cranium are thickened), the oxycephalic (or 
pointed head), the platycephalic (or flat head), the trocho cephalic 
(or round head), and the plagio cephalic (or asymmetric oblique 
head). 1 

In the new-born child the anterior fontanel measures from 2 to 2^4 
cms. (J4 to 1 in.); the occipitofrontal circumference, 34^2 cms. 
(13^/5 ins.); the occipitofrontal diameter, 11% cms. (4^ ins.); 
its occipitomental diameter, 13^4 cms. (5^3 ins.) ; bisacromial diam- 
eter, 12 cms. (4% ins.) ; intertrochanteric diameter, 9 or 10 cms. 
(3^2 or 4 ins.). The width of the large fontanel may be stated to 
be from 2 to 2 J / 2 cms. (}i to 1 in.). 

THE BRAIN. 



MALE 


FEMALE 


Normal 


Maximum 


Minimum 


Normal 


Maximum 


Minimum 


1400 (49| oz.) 


2222 (78i OZ. ) 


960 (34 oz.) 


1245 (44 oz.) 


1585 (55 oz.) 


880 (31 OZ.) 



The average male brain is about 9 per cent, heavier than that of 
the female. The maximum weight is attained at about 35 years of 
age in man, possibly somewhat later in the female. , The average 
weight of the cerebrum is about 1000 grammes; of the brain-stem and 
cerebellum, each 135 grammes. The weight of the pia and arachnoid 
is 25 to 40 grammes. The brain of the recently deceased Japanese 



1 Ziegler's Text-Book of Special Pathological Anatomy, English Translation by 
MacAlister and Cattell, vol. i, pp. 206, 207. 



WEIGHTS AND MEASUREMENTS 399 

anatomist, Taguchi, weighed 1920 grammes (67^4 ozs.), the body- 
weight being 49 kgs. Tourgenieff's brain weighed 2120 grammes 
(74% ozs.), while that of Rustan reached 2222 grammes (78^3 ozs.). 

The weight of the encephalon relative to that of the body is subject 
to great variation, but may approximately be put down as 1 to 36.5 in 
the adult male and 1 to 35.2 or 1 to 36.46 in the female. These figures 
are based on observations upon persons dying from more or less pro- 
longed disease, but in the cases of a few individuals who died suddenly 
from disease or accident the average ratio was found to be 1 to 41. 
The proportion to body-weight is much greater at birth than at any 
other period of extra-uterine life, being about 1 to 5.85 in the male 
and 1 to 6.5 in the female. 

The weight of the human cerebrum also bears a somewhat definite 
relation to the stature of the individual. The weight in ounces may be 
obtained for a male by dividing the height in inches by 1.6, and for 
a female by multiplying the quotient thus obtained by ff . The weight 
in grammes may be obtained by multiplying the height in centimetres 
by 7 for a male, and the product again by ff for a female. Thus, 

Weight in ounces of the mean cerebrum = — - 

1.0 

Weight in ounces of the mean female cerebrum = — X 

& 1.6 31 

Weight in grammes of the mean male cerebrum . . = height in centimetres X 7 
Weight in grammes of the mean female cerebrum = height in centimetres X 7 X — 

These proportions are slightly deficient for the higher and ex- 
cessive for the lower statures. 

Dimensions. — The mean cubic capacity of the male cranium is 
1450 ccs. (SSy 2 cu. ins.) ; that of the female is 1300 ccs. (79^3 cu. 
ins.). (Welcker.) The length of the male brain is from 160 to 
170 inms. (6^5 to 6jHs ins.) ; that of the female brain is from 150 to 
160 mms. (6 to 6% ins.). The greatest transverse diameter is 140 
mms. (sH ins.) ; the greatest vertical diameter is 125 mms. (5 ins.). 
The volume is about 1330 ccs. (81 cu. ins.). The specific gravity of 
the brain is from 1.035 to 1-040. 

Pituitary gland : Length, 0.008 metre ( y^ in. ) ; breadth, 
0.012 metre (^ in.); thickness, 0.065 metre (2^ in.); weight, 5 
gms. ( yy grs. ) . ( Zander. ) 

Pineal gland measures 0.01 metre ( 2 /s in.) by 0.005 metre 
(}i in.) by 0.005 metre (}i in.) (Charpy), and weighs 0.20 gm. 
(3 g rs 0- (Engel.) 



400 



POST-MORTEM EXAMINATIONS 



Spinal cord measures in the adult 0.448 metre (17:3/3 ins.), 
and its weight, deprived of its nerves, is 27 to 30 gms. (4i5to463grs.). 
The transverse diameter of the cervical enlargement, 0.013 metre (y 2 
in.) ; of the dorsal, 0.01 metre (% in.) ; of the lumbar, 0.012 metre 
(y 2 in.). The anteroposterior diameter of the cervical enlargement, 
0.009 metre (^ in.); of the dorsal, 0.008 metre (^ in.); of the 
lumbar, 0.009 metre (A in.). 

THE HEART. 

Weight. — The mean weight of the heart in the adult male is 
about 310 gms. (11 ozs.) ; its proportion to the body-weight is 1 to 
169. That of the adult female is about 255 gms. (9 ozs.) ; propor- 
tion to body-weight, 1 to 149. The specific gravity of the heart is 
1.055, or about that of the blood (1.058). The amount of blood in 
the entire body is ordinarily estimated at iV of the body-weight, but 
the later investigations of Haldane and Smith place it at 1 to 20.5. 

Dimensions. — The determination of the exact measurements of 
the heart is most difficult, as the muscular fibres contract and expand 
under such diverse circumstances and the positions of the parts are 
so different. Constantin Paul has called attention to the fixed manner 
in which the inferior vena cava enters into the heart on a line with 
the tip of the right auricular appendix. The heart is generally of about 
the same size as the right fist of the cadaver. Its extreme length is 
about 125 mms. (5ms.) ; width, 87 mms. (?y 2 i ns -) \ thickness, 62 mms. 
(2 T / 2 ins.), slightly less in the female than in the male. The thick- 
ness of the wall of the right ventricle is from 2 to 5 mms. ( T V to J /s 
in.) ; of the left ventricle, from 7 to 12 mms. (X to y$ in.) ; ventric- 
ular septum, 15 mms. (5/5 in.). Pathologically, these measurements 
may be increased threefold or more. 

The dimensions of the orifices of the heart are shown in the fol- 
lowing tabular statement : 

Orifices Diameter Circumference. Area. 

orifices. Diameter. Ma)e Female. Male. Female. 

Aortic 24 to 25 mms., or 81 mms. 76 mms. 530 sq. mms. 452 sq. mms. 

0.9 to 1 in. 
Mitral 30 to 35 mms., or 103 mms. 101 mms. 855 sq. mms. 804 sq. mms. 

1.2 to 1.4 ins. 
Pulmonary .... 27 to 30 mms., or 91 mms. 89 mms. 660 sq. mms. 615 sq. mms. 

1.1 to 1.2 ins. 
Tricuspid 37 to 45 mms., or 122 mms. 115 mms. 1194 sq. mms. 1017 sq. mms. 

1.5 to 1.8 ins. 



WEIGHTS AND MEASUREMENTS 



401 



In childhood the pulmonary orifice is wider than the aorta; at 
puberty, of equal width ; in the adult the converse holds good. 

Volume. — In the new-born the volume is about 20 to 25 ccs. 
( 2 A to 5/e fl. oz.), which is increased to 250-310 ccs. (8^ to ioy 2 
fl. ozs.) in the adult. Up to the age of puberty it is about the same 
in both sexes, but after that it is from 25 to 30 ccs. (^ to 1 fl. oz.) 
larger in the male. Because of obvious difficulties, these figures can 
only be regarded as approximate. 

Thickness of the aorta, ij4 to 2 mms. ( 2V to tu in.). (Orth.) 
Circumference of the thoracic aorta, 4 to 6 cms. ( 1 J / 2 to 2 ins. ) ; of 
the abdominal aorta, 35 to 45 cms. (13^4 to 17^4 ins.) ; weight, 35 
to 45 gms. (1% to 1% ozs.). The transverse sections of the aorta 
will about admit the thumb. The length of the inferior vena cava is 0.22 
to 0.25 metre (8% to 9% ins.) ; of the superior, 0.06 to 0.08 metre 
(2% to 3% ins.) ; of the great azygos, 0.20 to 0.25 metre (7% to 
g% ins.) ; and of the portal veins, 0.05 to 0.12 metre (2 to 4j4 ins.). 

THE THORACIC DUCT. 
The length of the thoracic duct is 0.30 to 0.34 metre (nj4 to 
13% ins.). 

THE LUNGS. 

Weight. — Obviously the lungs are subject to great variation in 
weight, depending upon the amount of blood or other liquid in their 
cavities. Their combined weight ranges from 850 to 1370 gms. (30 
to 48 ozs.), the average being from 1020 to 1190 gms. (36 to 42 
ozs.). (1300 gms. in the male and 1023 gms. in the female. — 
Krause.) The right is generally 59 gms. (2 ozs.) heavier than the 
left. The weight of the right lung is from 360 to 570 gms. (12^3 to 
20-J ozs.) ; that of the left lung, from 325 to 480 gms. (n^ to 17 
ozs.). The lungs are heavier in the male than in the female, and 
also appear to be heavier in proportion to the body-weight. 

Dimensions. — The extreme length of the right lung in the male 
is 271 mms. (10^/5 ins.), and that of the left is 298 mms. (12 ins.) ; 
in the female, 216 mms. (8^5 ins.), and 230 mms. (9^3 ins.), respec- 
tively. The extreme outer and posterior diameters in the male are, 
of the right, 203 mms. (8% ins.), and of the left, 176 mms. (7 ins.) ; 
and in the female, 176 mms. (7 ins.), and 162 mms. (6^> ins.), 
respectively. The transverse diameter at the base is, in the male, 

135 mms. ($}i ins.) for the right, and 129 mms. (5% ins.) for the 

26 



402 POST-MORTEM EXAMINATIONS 

left. In the female the measurements are 122 mms. (4% ins.), and 
108 mms. (43/3 ins.), respectively. (Krause, quoted by Vierordt.) 
The specific gravity of a healthy adult lung varies from 0.345 
to 0.746. When fully distended with air it is about 0.126, while 
that of the lung tissue itself, entirely deprived of air, is about 1.056; 
which is again about the specific gravity of the blood. 

THE SALIVARY GLANDS. 

Parotid (weight), 25 to 30 gms. (386 to 463 grs.) ; submaxillary, 
8 gms. (124 grs.) ; sublingual, 2 to 3 gms. (31 to 47 grs.). 

THE ALIMENTARY TRACT. 

(Esophagus, length, 0.26 metre (10% ins.) ; breadth, 0.045 metre 
(1J/5 ins.) ; thickness, 0.009 metre (^3 in.) ; weight, 40 gms. (617*4 
grs.). 

Stomach (empty), length, superior border, 0.09 metre (3% ins.) ; 
thickness, 0.007 metre ( ^5 in.) ; weight, 145 gms. (5-g- ozs.). 

Small intestine, length, 6 to 8 metres (19% to 26% ft.); 
weight, 640 to 730 gms. (22* to 25% ozs.) ; duodenum, length, 0.26 
metre (ioj4 ins.). Large intestine, length, 1.40 to 1.70 metres (45 
to 6y ins.) ; caecum, 0.08 to 0.1 metre (3% to 4 ins.) ; weight, 460 gms. 

Vermiform appendix, length, 0.04 to 0.08 metre (1^ to 3 ins.) ; 
weight, 7 to 20 gms. (100 to 300 grs.). The longest appendix of 
which we have found a record is 33 cms. (12% ins.). 

THE LIVER. 

Weight. — The liver weighs from 1400 to 1700 gms. (50 to 60 
ozs. ) in males, and a little less in females. The weight varies, whether 
before or after letting out the blood, especially in certain cardiac cases 
and in the enlargement from malaria. In a four-months' foetus it is 
about one-tenth of the body-weight; at birth it is one-twentieth; in 
the adult male it is one-fortieth; in the adult female it is one thirty- 
sixth. Supernumerary livers may weigh 28.35 & m s. C 1 oz or more. 

Dimensions. — The transverse diameter is from 1 50 to 300 millime- 
tres, or 6 to 12 inches; vertical diameter, from 75 to 175 millimetres, 
or 3 to 7 inches; and anteroposterior, from 75 to 175 millimetres, or 
3 to 7 inches. According to Orth, the transverse diameter of the liver 
varies from 25 to 30 centimetres, that of the right lobe being from 
18 to 20 centimetres and that of the left from 8 to 10 centimetres. 
The anteroposterior diameter averages from 19 to 21 centimetres, — 



WEIGHTS AND MEASUREMENTS 



403 



from 20 to 22 centimetres for the right lobe and 15 or 16 centimetres 
for the left. The greatest vertical diameter is from 6 to 9 centimetres. 
The hepatic lobules vary in size from 1 to 3 millimetres. 

Volume and Specific Gravity. — This varies from 1475 to 1638 ccs. 
(90 to 100 cu. ins.). The mean volume is 1574 ccs. (96 cu. ins.). 
The specific gravity is between 1.050 and 1.060, which in fatty degen- 
eration may be reduced to such an extent that small portions of the 
liver will float upon the water. 

Gall-bladder: length, 0.08 to 0.17 metre (3% to 6 2 /z ins.) ; diam- 
eter at base, 0.03 metre (i}i ins.) ; thickness of wall, 1 to 2 mms. 

(2V to A in - )• 

THE KIDNEYS. 

Weight. — Each kidney weighs from about 127.5 to 1 7° S ms - (4- 1 /* 
to 6 ozs.) in the male, and from 113 to 156 gms. (4 to $y 2 ozs.) in 
the female. The left kidney is usually a little heavier than the right, — 
from 5 to 7 gms. (y/ to 108 grs.) heavier. At the end of the first 
year the kidneys together weigh 62 gms. (2 ozs.). The ratio of the 
weight of the kidneys to the body is as 1 to 200. The mean propor- 
tion of the weight of the heart to the weight of the kidneys between 
the ages of twenty and thirty-five years is as 1 to 1.1 (Thoma). 

Dimensions. — Length, about 10 cms. (4 ins.); breadth, 5 to 6 
cms. (2 to 2 J /s ins.); and thickness, from 3 to 3.5 cms. (i*4 to 
i]/ 2 ins.) ; or in the proportion of about 1 to ^ to ^. The left 
kidney is usually a little longer and narrower than the right. 

Specific Gravity. — About 1.050. 

The following points serve to distinguish between the right and 
left kidneys : 

RIGHT KIDNEY. LEFT KIDNEY. 

Impression from liver. • No impression from spleen. 

Shorter and broader than its fellow. Longer and narrower than its fellow. 

From 5 to 7 grammes lighter than its About 5 to 7 grammes heavier than its 

fellow. fellow. 

The spermatic or ovarian vein empties The spermatic or ovarian vein empties 

into the inferior vena cava. into the renal vein. 

The right kidney is usually situated a little lower down in the body 
than its fellow, owing to the liver being larger than the spleen. 

In both kidneys the posterior surface is the flatter, the external 
border is convex, the internal border concave, and the upper portion is 
more expanded than the lower. At the hilum the attachment of ves- 



4 4 POST-MORTEM EXAMINATIONS 

sels and ureter is, from above downward, the body being in the erect 
posture, artery, vein, ureter ( AVU) ; and from before backward, vein, 
artery, ureter (VAU). Place the organ on the table, with its pos- 
terior surface down, the lower extremity (the ureter pointing down- 
ward) being towards the observer. The ureter is then behind and 
below the other vessels, and the hilum will be directed towards the 
side of the operator to which the kidney belongs, — i.e., towards the 
left hand if it is the left kidney, and towards the right hand if it is 
the right kidney. 

The ureters are from 27 to 30 cms. (io5/£ to 11% ins.) long, with 
a circumference of 1 cm. (% in.). Bladder: height, when empty, 
4 cms. (iy 2 ins.) ; transverse diameter, 6 to 7 cms. (2^ to 2% ins.) ; 
weight, 30 to 60 gms. ( 1 to 2 ozs.). Urethra: male, 15 to 17 cms. 
($H to 694 ins.); female, 3.5 cms. (i}i ins.), with a diameter of 
7 to 10 mms. (}i to 3/5 in.). 

THE ADRENALS (SUPRARENAL BODIES). 

Weight. — Each suprarenal weighs about 5 gms. (75 grs.), the 
left being slightly the heavier. They are nearly as large at birth as 
in adult life. 

Dimensions. — Vertical length is from 30 to 50 mms. ( 1 % to 2 
ins.) ; breadth, from side to side, about 30 mms. (ij4 ins.) ; thickness, 
from 5 to 6 mms. ( }i to }i in. ) . 

THE SPLEEN. 

Weight. — This organ varies in health within wide limits in both 
size and weight. Ordinarily its weight is between 100 and 300 gms. 
(3^2 and 10 ozs.), with the average at about 170 gms. (6 ozs.). 
In intermittent and sometimes other fevers it may weigh 18 to 20 lbs. 
Its weight in proportion to the body-weight is at birth about 1 to 350; 
in the adult, 1 to from 320 to 400 ; and in old age, 1 to 700. 

Dimensions. — Generally the spleen is from 125 to 150 mms. (5 
to 6 ins.) in length; from 75 to 90 mms. (3 to 3^ ins.) in breadth; 
and from 25 to 40 mms. (1 to ij4 ins.) in thickness.- 

Volume. — This does not usually exceed from 200 to 300 ccs. (12 
to 18 cu. ins.). 

THE PANCREAS. 

Weight. — The weight is variable, — from 30 to 100 gms. (1 oz. to 
3>4 ozs.) ; it may even be 170 gms. (6 ozs.) in adults. 



WEIGHTS AND MEASUREMENTS 405 

Dimensions. — Length, 23 cms. (9 ins.); breadth, 4.5 cms. (ij4 
ins.); thickness, 3.8 cms. (iY ins.). (Orth.) 
Specific Gravity. — 1.046. 

THE THYMUS GLAND. 

Weight. — See p. 107. 

Dimensions. — At birth the length is about 60 rams. (2^5 ins.) ; 
width, 37 mms. (ij4 ins.) ; and thickness, from 6 to 8 mms. (J^ to 
Yz in.). From birth to the second month the length is 5.2 cms. (2 
ins.) ; from the ninth month to the second year, 6.96 cms. (2% ins.) ; 
and from the third to the fourteenth year, 8.44 cms. (33/3 ins.). The 
breadth across the middle is from 2.7 to 4.1 cms. (1 to 1J/5 ins.); 
above and below, from 0.7 to 0.9 cm. (A to ^5- in.). ( Friedleben. ) 

THE THYROID GLAND. 

Weight. — From 28 to 56 gms. ( 1 to 2 ozs. ) , being larger in the 
female. 

Dimensions. — Each lateral lobe is about 50 mms. (2 ins.) in 

length, from 18 to 30 mms. (Y to 1% ins.) in breadth, and from 18 

to 25 mms. (24 to 1 in.) in thickness. The right lobe is usually the 

larger. The isthmus is nearly 12 mms. (Y in.) in breadth, and from 
6 to 18 mms. (Y t0 H m -) i n depth. 

THE TESTES. 

Weight. — Each testicle with its epididymis weighs from 18 to 25 
gms. (4^2 to 6 drs.), the left being slightly the heavier. 

Dimensions. — Length, about 37 mms. (iY ins.) ; breadth, antero- 
posterior, 30 mms. (1*4 ins.) ; thickness, from side to side, 24 mms. 

(1 in.). 

THE OVARIES. 

Weight. — From 4 to 8 gms. ( 1 to 2 drs. ) . 

Dimensions. — Length, usually about 37 mms. (iY ins.) ; breadth, 
18 mms. (Y in-) ', thickness, 12 mms. (Y in.). The right is usually 
a little larger than the left. 

Nauwerck, quoting from Puech, gives the following dimensions : 

Length, maidens from 4.1 to 5.2 cms. ( if to 2 ins. ). 

Length, women from 2.7 to 4. 1 cms. ( I to if ins. ). 

Breadth, maidens from 2.0 to 2.7 cms. (f to I in. ). 

Breadth, women from 1.4 to 1.6 cms. (| to f in. ). 

Thickness, maidens from 1.0 to 1. 1 cms. (J- to -|-J- in.). 

Thickness, women from 0.7 to 0.9 cms. (| to f in. ). 



40 5 POST-MORTEM EXAMINATIONS 

THE UTERUS. 

Weight. — Generally from 28 to 42 gms. (1 to ij/ 2 ozs.) in vir- 
gins and 105 to 120 gms. in multipara. 

Dimensions. — The virgin uterus is from 5.5 to 8 cms. long, 
from 3.5 to 4 cms. broad, and from 2 to 2.5 cms. thick; in multiparas 
the womb is from 9 to 9.5 cms. long, from 5.5 to 6 cms. broad, 
and from 3 to 3.5 cms. thick. The walls of the virgin uterus are 
from 1 to 1.5 cms. thick; of the cervix, from 0.7 to 0.8 cms. thick. 
In multiparas the uterine walls may be as thick ' as 2 cms. and the 
cervix is from 0.8 to 0.9 cm. thick. (Orth.) 

The length of the uterine cavity in virgins is 5.2 cms., after the 
menopause 5.6 cms. ; in multiparas 5.7 cms., after the menopause 
6.2 cms. (Nauwerck.) 

THE BREASTS. 

Weight. — Breasts at birth, 0.30 to 0.60 gm. (4^ to 9% g r s.) ; of 
adult, 150 to 200 gms. (5^ to 7 ozs.) ; during lactation, 400 to 900 
gms. (14 to 31^4 ozs.). 

THE PROSTATE AND SEMINAL VESICLES. 

Weight. — Average, from 18 to 20 gms. (4^ to 4% drs.). 

Dimensions. — Transverse diameter, about 37 mms. (iy 2 ins.); 
vertical, 30 mms. (1% ins.); anteroposterior, 18 mms. (^4 in.). 
These measurements are subject to great variation, according to the 
fulness of the rectum and bladder. 

The seminal vesicles measure 4.2 by 17 by 0.9 cm. (1% by 6% 
by y 3 in.). 

(For elaborate tables showing the average dimensions and weights 
of the various parts and organs of the human body, the reader is re- 
ferred to volume one of the National Medical Dictionary, by Billings. 
The regulations for making medicolegal autopsies in Bavaria, as 
amended in 1897, also give some weights and measurements of value.) 



CHAPTER XXV 



The great number, importance, and variety of diseases which 
human beings may contract from the lower animals are increasingly 
obtaining recognition. Our domestic animals suffer from nearly 
all the contagious maladies found in man, and impart to him various 
disorders from which he would otherwise be exempt, such as glanders, 
actinomycosis, anthrax, hydrophobia, foot-and-mouth disease, echino- 
coccus cysts, trypanosomiasis, etc. The rat disseminates bubonic 
plague, the mosquito malaria, yellow fever, and dengue, and the pig 
trichinosis, and were it not for the rat, the mosquito, and the pig these 
diseases would probably cease to exist. The lower animals are espe- 
cially rich in parasitic diseases and in malformations. As stated by 
Orth, the advantages of a study of animal pathology is that the neces- 
sary material is easy to obtain, and by voluntary killing accurate 
morphologic investigations may be made in a perfectly fresh condition 
at any desired stage of the disease. 

Many of the suggestions made in the previous chapters apply with 
equal force to the performance of necropsies upon the lower animals. 
Such examinations are of two distinct classes, — veterinary postmor- 
tems and laboratory postmortems. For laboratory study small ani- 
mals, such as the guinea-pig (Fig. 187), rabbit (Fig. 188), mouse, 
and rat, are generally chosen, while in veterinary investigation the 
subject is usually a dog, a horse, a cow, sheep, goat, or cat. So 
intense is the interest now taken in comparative pathology that all 
classes of animals come to section, even reptiles (especially snakes) 
receiving no small amount of attention. 

Instruments. — In post-mortem examinations of the large domes- 
tic animals (cow, horse, mule, etc.) the instruments used must neces- 
sarily be larger than those employed in human autopsies. The 
following is a partial list: (1) Large butcher's knife, to remove the 
skin, expose the thorax and abdomen, and incise the organs; (2) large 

1 Much of the material and all the illustrations in this chapter are taken from 

Kitt's excellent work entitled Lehrbuch der pathologischen Anatomie der Haus- 

thiere, 1905, vol. i, pp. 1-56, and 1900, vol. ii, pp. 1-54. 

407 



40 g POST-MORTEM EXAMINATIONS 

cleaver; (3) large butcher's saw, to open the thoracic and cranial 
cavities, expose the nasal septum, etc.; (4) large chisel, to remove the 
cord; (5) hammer, for the same purpose; (6) bone-forceps (cos- 
totome) ; (7) enterotome; (8) scissors; (9) brain-knife; (10) dissect- 
ing forceps ; ( 1 1 ) large needle ; (12) a meat-axe, watering can, strong 
twine, etc. Kitt cautions the veterinarian against using the same knife 
for a pathologic postmortem that is subsequently to be used upon 
an animal whose flesh is to be eaten. 

Utensils. — Buckets, pitchers, large and small enamelled plates, 
sponges, soap, towels, and disinfectants, and green soap or lysol are 
especially useful. 

Clothing. — An operator's apron may be drawn over the clothes 
or an ordinary rain-coat worn, but a special suit for operating is better. 

General Suggestions. — In many cases the necropsy must be 
made at the place where death occurred, be this in the fields, stable, 
slaughter-house, or veterinary morgue. The procedure will vary with 
the conditions and conveniences, but the end in view should be care- 
fully considered and certain general rules observed. If the animal is 
alive, the method of killing to prepare for the desired investigation 
should be one that will not injure the organs involved. In cerebral 
trouble the animal should not be killed by a blow upon the head, but 
by poison or chloroform ; in inflammatory conditions all loss of blood 
should be avoided ; if the trouble is in the digestive system, no poison 
should be used; and in pulmonary affections the animal must not be 
shot through the heart (Csokor). 

Operative Technic. — In opening the cadaver the normal position 
of the intestines should be retained as far as possible, and they should 
be carefully examined to see that they are uninjured and are suffi- 
ciently exposed. Horses, large and small ruminants, and the larger 
swine are usually placed upon the left side of the body so that the right 
side may be opened. A dorsal position may be chosen for dogs and 
cats, and even for swine or larger animals if sufficient assistance be 
present, as it gives a better view of the abdominal cavity. 

The postmortem is begun by removing the hide, which- has a market 
value and must not be injured. As scalpels and straight-edged knives 
are apt to button-hole the skin, a butcher-knife with rough cutting edge 
is to be preferred. Beginning at the angle of the chin a longitudinal 
incision is made down the median line the whole length of the body, 
avoiding the udder, prepuce, and scrotum, and the navel in the case 



POST-MORTEM EXAMINATIONS OF THE LOWER ANIMALS 409 

of young animals. A transverse incision is made perpendicular to 
the first along the median surface of the foreleg and the skin is drawn 
back from the edges up over the dorsal surface. A similar cut is made 
upon the median surface of the thigh and leg down to the tuberosity of 
the os calcis. On both the limbs and the body the hair-seams will serve 
as a useful guide for the knife. A circular incision is made around the 
head from angle to angle at the lips, thus permitting the removal of 
the eyelids, ears, etc. If the head is to be preserved, as in the case of a 
deer, the circular incision is made at the manubrium. The skin may 
be detached either with the hands or with the handle of a chisel, and 
is more easily removed when the animal is warm than after rigidity 
has set in. 

Removal of the Extremities. — After the animal has been 
skinned, it is placed on its side, and the uppermost limbs are removed 
in order to secure more room for subsequent manipulation. First the 
foreleg is held up by an assistant and the shoulder- joint disarticulated. 
The musculature of the part is cut through in the median portion by 
a butcher-knife grasped firmly by the whole hand. During the exsec- 
tion the extremity should be constantly raised by an assistant and the 
blade of the knife should be held somewhat towards the thorax so as to 
cut obliquely to the ribs. 

To remove the posterior extremity make a deep circular incision 
through the hip muscles, beginning with the broad crural fascia and 
above the large trochanter, passing up over and through the muscula- 
ture of the croup and downward and outward into the ischiatic fossa, 
but not behind the tuberosity of the ischium; raise the foot; cut 
through the adductors in a line with the acetabulum, open its capsular 
ligament, and section the round ligament. The incision of the capsular 
ligament is accompanied by a snapping sound, due to the entrance of 
air into the joint. The limb can now be drawn backward, the remain- 
ing fascia and muscles sectioned, and the whole removed. 

Exposure of the Abdominal Cavity. — Before opening the ab- 
dominal cavity of a filly the udder should be entirely removed from the 
abdominal wall, and in geldings and stallions the scrotum and the 
penis should be isolated and thrown back, and in newly born animals 
the umbilicus and adjacent parts are not to be injured. It should be 
remembered that in herbivora meteorism occurs soon after death, so 
that the intestines are pressed up closely against the abdominal wall 
and may easily be injured. 



4IO POST-MORTEM EXAMINATIONS 

The operator should stand in the space between the remaining 
extremities with his face towards the breast of the animal. An incision 
is made through the median line of the body, beginning with the 
ensiform cartilage of the sternum, extending as far as the pubic region, 
cutting through the muscles and fascia only and not injuring the peri- 
toneum. This will not be difficult if the blade of the knife be held 
flat and the ball of the thumb placed near the edge and close to the 
point. As the peritoneum is carefully torn through with the fingers, 
the exit of gases, liquids, or abnormal contents of the abdominal cavity 
should be noted, as well as the position of the intestines. The index- 
and middle fingers are then separated so as to form a V-shaped space, 
in which the knife is placed and its point thrust through the abdominal 
wall along the line of the linea alba, the fingers following. At the 
posterior end of the longitudinal incision a second incision is made, 
perpendicular to the first, extending from the pubic region to the 
lumbar. The right upper half of the abdominal wall is held up by its 
edges with the left hand. The assistant pulls on the lower ribs in order 
to make the abdomen tense, and its covering is cut through with sawing 
strokes of the knife as far as the costal processes. The knife is so 
held by the whole hand that the point is shoved away from the operator 
towards the lumbar region and the lower part of the blade is used 
instead of the point. 

We have now a large anterior and a small posterior segment of the 
abdominal wall. They may easily be drawn back and a view of the 
abdominal organs obtained. The ribs of the horse extend so low down 
that a sufficiently extensive view for pathologic purposes cannot be 
obtained; therefore, before removing the abdominal contents the tho- 
racic cavity is exposed. Then, by thrusting the hand well up under 
the lower ribs, we notice whether the diaphragm is tightly vaulted 
forward or is more or less relaxed. 

Exposure of the Thoracic Cavity. — A small incision is made 
between two of the true ribs and note is taken whether or not air enters 
the thoracic cavity and the diaphragm becomes relaxed. If the ab- 
dominal examination showed the diaphragm drawn down posteriorly, 
the incision should receive special attention; instead of air entering, 
there may be an exit of gas from the pleural cavity, indicating some 
essentially pathologic condition. Whether there be a positive or 
negative pressure may readily be determined by a trocar connected 
by a rubber tube with a V-shaped tube filled with mercury. 



POST-MORTEM EXAMINATIONS OF THE LOWER ANIMALS 411 

The direction for cutting the ribs is through the costal angles fol- 
lowing the course of the iliocostal muscle. An incision is made 
between the true ribs and the blade of the saw introduced, an assistant 
making the breast tense while the sawing is done ; very little pressure 



Rectum 



Temporomaxillary articulation 
after separation of half of the 
lower jaw 




Fig. 189. — Equine viscera, the animal resting on its right side,"the anterior and posterior left limbs 
having been removed, and the abdominal, thoracic, oral, and pharyngeal cavities opened. The double 
lines show the places in the intestines which are to be tied previous to being cut. 



should be used or the bone will splinter. When the ribs have been 
sawed through, they are turned over towards the median line and 
removed by severing the costal cartilages. The situation of the organs 
and the pathologic contents should be carefully noted. (Fig. 189.) 

Removal of the Abdominal Contents in the Right Lateral 
Position. — After exposing the abdominal cavity by the longitudinal 
and transverse incisions, pull the two left coils of the colon either up 



412 



POST-MORTEM EXAMINATIONS 



over the thorax or out across the body on the right side, so that the 
sigmoid flexure looks towards the head or lies on the ground and the 
body and tip of the caecum come into view. Spread the mesorectum 
out over the left flank and pelvic region. Stroke back the faeces, doubly 



Duodenum 



Cut end of the rectum 



Spleen 




Fig. 190. — Further dissection of animal seen in Fig. 189. Appearance of the parts after removal of the 

rectum, ileum, and jejunum. 



ligate the rectum at its entrance into the pelvis, and section. Cut away 
the mesorectum up to its origin at the rectoduodenal ligament, doubly 
ligate the rectum, section, and remove. 

The ileum is easily recognized by its thicker walls and its entrance 
into the caecum. Apply a double ligature, section, and, holding the 
intestine in the hand, cut away all the mesentery from 'the whole of 
the small intestine as far as the rectoduodenal ligament, divide this, 
doubly ligate the duodenum, and section. The junction of the colon 
with the rectum is now exposed, — the so-called stomach-like or gas- 
troid dilatation, — under which lies the anterior root of the mesentery. 
Grasping the dilatation with the left hand (Fig. 190), pull it towards 



POST-MORTEM EXAMINATIONS OF THE LOWER ANIMALS ^3 

the caecum, and with the right hand work loose or cut partly away 
the connections between the gastroid dilatation and caecum and the 
omental sac, kidney, and pancreas. In this way better access to the 
portal vein and anterior root of the mesentery is obtained. With the 
fingers work through the cellular tissue surrounding the root of the 
mesentery, grasp it with the hand, and together with the portal vein 
cut it away close to the intestine, leaving as much of it as possible with 
the aorta. The colon and caecum are now drawn out of the cavity, all 
the remaining sections being easily torn or cut away, while the right 
branch of the pancreas which lies upon the caecum and the root of the 
mesentery must be carefully dissected away. Grasp the spleen, section 
the suspensory (gastrosplenic) ligament and the gastrosplenic omen- 
tum, and free the spleen from the stomach. Separate the branches of 
the pancreas from the larger blood-vessels and the kidneys, so that it 
hangs only by its body from the liver, and leave it in this position or, 
after examining its excretory duct, cut it away. Next remove the 
stomach and duodenum by cutting along the sigmoid curvature and the 
smaller curvature of the stomach and by sectioning the duodenorenal 
ligament, the hepatic and pancreatic ducts, the diaphragmatic and 
gastrohepatic ligaments, and the oesophagus, after pulling the latter 
down as far as possible from the diaphragm. Excision of the liver is 
an easy matter : section first the left lateral ligament, then the coronary 
and suspensory ligaments, the vena cava on the anterior surface of the 
liver, the right lateral portion of the coronary ligament, and the right 
hepatic and renal hepatic ligaments. 

Removal of the Abdominal Contents in the Left Lateral 
Position. — The rectum is sectioned at its entrance into the pelvis after 
pressing back the faeces with the fingers, applying a double ligature, 
and cutting between them. Seize the colon at its anterior curvature 
and pull it carefully out of the abdominal cavity as far as possible. 
The left folds of the colon will fall out with very little assistance. 
(Fig. 191.) 

In the region of the kidney will be seen the arch of the duodenum 
lying between the anterior and posterior roots of the mesentery and 
covered by the ribs. Cut through this arch and its mesentery, after 
applying a double ligature, and remove. The cellular tissue lying 
between the caecum and psoas muscle and the right kidney should be 
carefully worked loose and the pancreas separated from the caecum and 
the colon; this is done by tearing or cutting through the peritoneum 



414 



POST-MORTEM EXAMINATIONS 



covering the intestine and pancreas, getting the hand in under the 
pancreas, and working it loose. Beginning posteriorly, cut away the 
mesorectum from behind forward and any connections that may 
remain between the caecum and colon and the region of the kidney, 
grasp as much as possible of the attachment of the mesentery, pull the 
intestine back away from the kidney, and section the root of the mesen- 
tery in front of the left hand, as far from the aorta as possible. With 



Duodenum 



Iliac spinal column 




Root of the mesentery and portal vein 



Line for sawing ischio- 
pubic suture 



Fig. 191. — Further dissection of animal seen in Figs. 189 and 190. Appearance of the parts after removal 

of the large intestine. 

the exception of a small portion of the duodenum and the pelvic por- 
tion of the rectum the large and small intestines can be drawn out 
from the abdominal cavity by cutting or tearing away any attachments 
which may remain ; the operator stands alternately at the back and in 
front of the cadaver while removing these portions. 

Removal of the Kidneys, Stomach, Liver, and Spleen. — The 
removal of the kidneys leaves a freer field for the stomach, spleen, and 
liver. With the hand and fingers separate first the right and then the 
left kidney and the suprarenal capsules from the surrounding cellular 
tissue. If the ureters and kidneys are intact the kidneys may at once 
be cut away together with their vessels. In case of any abnormalities 
they should be left hanging or a sufficient length of the ureters removed 



POST-MORTEM EXAMINATIONS OF THE LOWER ANIMALS 4^ 

with them, together with the surrounding tissues, or they may remain 
attached to their ureters and be placed in the pelvic region. 

The pancreas, spleen, and stomach are freed from the mesentery 
and sectioned. The assistant pulls on the right side of the diaphragm, 
and the inferior vena cava between it and the liver is cut through, 
together with the oesophagus and the right hepatic ligament. The 
stomach is turned backward. The left hepatic ligament is sectioned 
and all the three organs removed together in a mass. 

If the kidneys are left in place, the exenteration of the stomach, 
pancreas, and liver is more difficult and demands more caution, espe- 
cially if the animal has not been bled, because the field is obscured by 
blood and other impurities. Dissect away carefully the attachments 
of the right kidney to the suprarenal capsule and left branch of the 
pancreas, which lies deep down, covered by the branches of the mesen- 
teric arteries ; next the adrenals, then the fundus of the stomach from 
the crura of the diaphragm, the suspensory ligament of the spleen, the 
splenorenal ligament, the right coronary and lateral ligaments of the 
liver, the hepatic renal ligament, the vena cava, with the falciform 
ligament, the oesophagus, and the left lateral and coronary ligaments 
of the liver. 

All these organs may be removed with the diaphragm, and, when 
there are adhesions to its posterior surface, this is the preferable 
method. The right lobe of the liver is first separated from the kidney ; 
the pancreas, spleen, and stomach are worked loose from the spinal 
column; the posterior vena cava, the oesophagus, and the pulmonary 
attachments to the diaphragm are sectioned; the diaphragm is freed 
from the thoracic wall by a circular excision, and the whole mass 
removed together. Finally, the aorta and the venae cavae with their 
branches are dissected off the spinal column from the diaphragm to the 
pelvis. 

Exenteration in the Dorsal Position. — The body may be 
kept on its back by tying the feet to rings in the wall or to posts or 
poles. The extremities remain attached to the body, of course, and the 
broad muscles of the chest are only to be sufficiently incised to permit 
the anterior extremities to spring out a little and give access to the 
chest. If during the postmortem the extremities are released too 
much, the body will fall to one side and make the exenteration more 
difficult. 

A longitudinal median incision is first made, then a bilateral trans- 



4I 6 POST-MORTEM EXAMINATIONS 

verse incision just posterior to the last ribs. The two left folds of the 
colon are drawn up over the right side of the body. The rectum is 
pulled out and spread over the left thigh and left ventral wall and the 
small intestine spread out over the region of the lower ribs. The ileum 
is found at its insertion into the caecum; it is thicker than the rest of 
the small intestine. It is tied off and sectioned, remaining in the hand 
after its mesentery is severed close up to the intestine. In this way the 
whole of the right lateral small intestine is removed from the abdomi- 
nal cavity and its mesentery left hanging by its root. When it passes 
into the duodenum between the two roots of the mesentery, doubly 
ligate and section. Doubly ligate and section the rectum at its entrance 
into the pelvis and again at its junction with the colon. 

The pancreas and first part of the duodenum are dissected away 
from the colon as in the first method. The roots of the mesentery and 
both the branches going to the large intestine are sectioned close up 
and the large intestine is removed. 

The stomach, spleen, etc., are removed as in the first method. 
Many operators prefer to excise the spleen and open the stomach along 
its greater curvature and the duodenum on its inferior surface, where- 
upon the pathway of the bile ducts may be determined and then the 
empty organs cut away. 

In the dorsal position the thoracic organs may be ablated by draw- 
ing them down towards the abdominal cavity. An incision is made 
between the rings of the trachea, two fingers are inserted, the trachea 
is grasped firmly, and the larger vessels are sectioned at the thoracic 
inlet ; the aorta is dissected away from the vertebrae and the posterior 
vena cava and oesophagus are sectioned. If it be desired to remove 
the thoracic viscera together with the trachea and cervical organs, the 
first rib is sawed through and excised; the cervical organs are then 
ablated according to the method to be described later. 

Vienna Method of Exenteration in the Left Lateral Posi- 
tion. — Csokor's quick method for removing the thoracic and abdomi- 
nal contents is as follows : The extremities are removed and the 
abdominal cavity is exposed by a longitudinal and a transverse incision 
as in the first method ; then the muscles of the back are cleared away 
and the sectioned abdominal wall is drawn up by a hook. With a 
hatchet each rib is cut away from the spinal column and then from the 
breast-bone. The whole right wall of the thorax and abdomen is now 
drawn up over the head of the animal and the contents of both cavities 



POST-MORTEM EXAMINATIONS OF THE LOWER ANIMALS 417 

are exposed. The right kidney is next removed and then the thoracic 
contents. After their ablation the cardiac end of the stomach is freed 
from the diaphragm and the duodenum is detached from the liver and 
its surroundings and excised together with the stomach and spleen. 
The abdominal aorta is separated from the spinal column, the rectum 
sectioned, and all the intestines removed. The remaining organs are 
extirpated as in the other methods. This modification permits a very 
rapid necropsy, but the removal of the stomach and spleen is somewhat 
difficult. 

Discission of the Abdominal Contents. — To ascertain the 
macroscopic conditions of the abdominal contents it is necessary to 
make a few special incisions. The aorta is first examined and its dorsal 
wall slit up with the shears to expose the entrances into its branches, 
which are then cut open. On account of its great frequency, close 
search is to be made for an aneurism in the root of the mesentery. It 
is usually felt externally as a thick, cystic expansion. The branches to 
the small intestine — the duodenal, jejunal, and iliac arteries — are first 
given off from the short trunk of the artery lying in the root of the 
mesentery (the anterior mesenteric artery) ; next a large vessel, the 
ileocolic artery, which gives off a large branch, the inferior colic, and 
the ileocecal artery with its three branches. The superior colic comes 
off above the root of the mesentery on a level with the anterior rectal 
artery. After examining these branches slit the inferior and superior 
colic arteries in the mesocolon from their origin to the sigmoid flexure. 
If it seems necessary, examine the arteries of the small intestine in 
the same way and observe the mesenteric lymph-nodes. The bowel is 
opened with the shears along the line of the attachment of the mesen- 
tery so as to get a good view of Peyer's patches; keep the intestine 
lying flat, for if held up the contents run down into the lower portions, 
and are then troublesome. 

If the stomach is sufficiently full, cut it open with a knife along its 
greater curvature. If the duodenal portion remains with the stomach 
and liver, open it with the shears on its inferior surface in such a way 
that the termini of the hepatic and pancreatic ducts will not be injured 
and their patency may be demonstrated. Press and push along the 
course of the ducts so as to force out their contents. If there is any 
suspicion of abnormalities in these ducts, it is better to leave the 
stomach and duodenum in place and to open them before removal. 

Removal of the Thoracic Contents. — First carefully examine 

27 



4 i 8 POST-MORTEM EXAMINATIONS 

for sharp points of bone and excise them with cutting forceps. The 
pericardium should then be examined and worked free with the hands. 
The posterior vena cava is tied off and divided between the ligature 
and the diaphragm; the attachments of the liver and heart to the 
diaphragm are sectioned and an incision is made obliquely through the 
aorta down to the vertebral column. Thrust the finger into the pos- 
terior aorta, pull it up, and cut along the spinal column in the line of 
the vena azygos and the attachment of the longus colli. Now make 
an oblique section through the oesophagus, trachea, anterior aorta, and 
anterior vena cava along the line of the first rib, so that the thoracic 
organs may be removed. This avoids cutting the large veins, which 
bleed so freely as greatly to obstruct the view of the parts under 
observation. 

Section of the Oral Cavity and Cervical Organs. — This is 
begun by removing the ramus of the lower jaw on one side. Cut the 
buccal parietes and the cheek at the angle of the lips up to the zygo- 
matic arch, between the molar teeth and the space between the lower 
jaw and the large maxillary swelling, dividing the masseter and saw- 
ing through the bones. The ramus of the jaw may now be worked up 
and down, its muscular connections severed by a knife introduced 
along its median surface, and an incision made between the parotid 
gland and the posterior border of the bone. The temporal muscle is 
cut through above the coronoid process and the ligaments and capsule 
of the joint are sectioned, the jaw being moved up and down to find 
the joint. After examining the local conditions, sever the left connec- 
tions of the tongue with the jaw and- the soft palate; saw through 
both to the large branches of the hyoid bone. The larynx, trachea, 
and oesophagus are easily freed from their loose cellular tissue by 
cutting into the channel of the external jugular vein, between the 
longus colli muscle and the oesophagus, so that the thyroid gland is 
not injured. 

Dissection of the Thoracic and Cervical Organs. — In order 
more closely to inspect these organs, cut through the vault of the velum 
palati with the shears and continue down into the oesophagus, section- 
ing it dor sally. With the knife grasped firmly incise the larynx in the 
median dorsal line between the arytenoids. Pushing the oesophagus 
aside, cut the posterior muscular ligament of the trachea with shears 
throughout its whole length and thrust the cartilages apart to get a 
good view of the interior. The lobes of the lungs are laid open with 



POST-MORTEM EXAMINATIONS OF THE LOWER ANIMALS ^ig 

long, deep, bisecting strokes, and portions of each lobe are tested by 
throwing them into water to see whether they contain air and will 
float or will sink because of collapse or the presence of an exudate. 
The lymph-nodules around the roots of the bronchi should always be 
examined and sectioned. 

If the heart is hacked into or improperly opened, the distinctive 
appearance of any abnormality that may be present is destroyed, and 
these anomalies are of great importance to the whole organism. First 
make an incision into the right ventricle along the septum, insert the 
shears, and cut up into the pulmonalis. Holding the heart by this flap, 
lengthen the incisions towards the apex and the flap so as to get a 
better view of the ventricle. In the same way incise the left ventricle 
close to the septum and on the anterior surface ; insert a finger through 
the opening, find the entrance into the aorta, and with the shears cut 
down between the pulmonalis and the left auricle. It is true that in this 
way both semilunar valves are sectioned, but the auriculoventricular 
valves are spared and they are much more likely to present abnormali- 
ties than the semilunar. The size of the openings can be tested by 
inserting a finger, and the thickness of the walls measured, after which 
each auricle is cut through up into its vessels and a good view of their 
openings obtained. 

Exenteration of the Pelvis. — The removal of the pelvic organs 
is preceded by the previously described excision of the kidneys and 
ureters and in males by the exposure of the testicles and the external 
genitalia. The scrotum and penis were then turned back, and now 
their dorsal suspensory ligament and surroundings are divided as far 
as the ischiatic notch and all the flesh lying ventrad to the ischiatic 
suture is carefully cleaned away. The scrotum and the right and left 
inguinal canals are split open and the testicles together with the sper- 
matic vessels pulled up into the abdomen. It is especially necessary 
to cut the tendinous ligament which binds the corpora cavernosa to the 
ischium close to the bone, as well as the strong ischiopenile muscle. 
Two sections made by sawing will remove the right wall of the pelvis. 
The first one is made through the ischiopubic suture over the acetab- 
ulum to the iliac spinal column; the second, through the thin part of 
the iliac bone, after cutting away the flesh that lies over the acetabulum 
on the iliac column. By cutting the bone loose from the pelvic cellular 
tissue, it is easily pulled away. 

The lateral wall of the pelvis being removed and a good view of 



420 



POST-MORTEM EXAMINATIONS 



the organs obtained, divide the connective tissue between the rectum 
and the superior pelvic wall ; free the uterus and ovaries, the neck of 
the bladder, the vagina, and the accessory sexual glands ; cut through 
the strong rectococcygei and the skin between the tail and the anus; 
and make a circular incision around the anus and the vulva (or the 
region of the penis). Remove the whole mass and section the organs 
dorsally. 





s, 

i 



Fig. 192. — Lines to guide the saw in opening the cephalic cavities of a horse. 

Exenteration of the Cranial Cavity. — To remove the head 
from the trunk we may either cut around the joint as if the throat were 
being cut or puncture the capsule ventrally and amputate between the 
condyles and the atlas. It is best to remove the whole of the lower 
jaw and let the skull, wrapped in a cloth, rest on its base and the molar 
teeth; it may then be held much more steadily than if the inferior 
maxilla had been left in place. The cranial attachments of the cer- 
vical and temporal muscles are next cut away and the soft parts re- 
moved from the roof of the skull. 

There are three lines for sectioning the cranium. The first lies 
transversely across the forehead about a thumb's breadth above the 
upper border of both superciliary ridges. The two other lines begin 
at the ends of the frontal incision, pass backward across the temples 
and petrous bones, and converge to the condyloid apophyses (Figs. 
192 and 193). The first section can be made continuously, but the 
second and third will have to be done in several portions on account of 
the convexity of the cranium. 

The walls of the cranial vault are not equally thick, and care must 
be taken not to penetrate too deeply into the middle of the parietal 
bones and the squamous portion of the temporal bones. The frontal 



POST-MORTEM EXAMINATIONS OF THE LOWER ANIMALS 421 

section passes through the frontal sinuses, so that there is very little 
danger here; and the same is true of the vertex and the pyramidal 
region above the condyles. The plates are not usually sawed clear 
through along the whole line, but the connections are broken with a 
chisel. Rest the palm of the hand upon the skull, grasp the chisel 
firmly near its edge so that it cannot enter too deeply, and tap gently 
with the hammer. When the bones are completely severed, pry the 
piece off by rocking the chisel backward and forward, first in the 
frontal and then in the condylar region. A sudden strong pull on the 
pericranium, grasping it at the edge of the frontal section, will gen- 
erally separate it from the other parts of the head; sometimes the 
whole brain will come away at one jerk, together with the root of the 
skull. 






Fig. 193.— Lines of sawing for opening the cranial cavity of a horse. 

If the dura is too closely held or is adherent to the inner table of 
the skull, with the shears incise it in the line of the section in such a 
manner that the dorsal portion will come away with the calvarium. 
Next excise the longitudinal and transverse blood-vessels in the duras. 
That part, of the dura lying over the hemispheres is held up with 
forceps and cut with scissors so that it may be thrown back on both 



4 22 POST-MORTEM EXAMINATIONS 

sides. The tentorium is sectioned anteriorly and posteriorly and re- 
moved. The membranous transverse septum which is torn away from 
the falx is incised laterally and pulled out from the transverse fissure, 
due attention being paid to its vascularity. 

Dissection of the Brain. — After examining the pia mater and 
the superficial surface of the brain, the hemispheres should be separated 
so as to expose the corpus callosum. The interior of the brain may 
either be examined now or after its removal. A horizontal incision is 
made immediately over the corpus callosum, starting at the median 
surface, and using preferably the so-called ".brain-knife" or a long, 
flat scalpel. If the incision is not quite deep enough to enter the lateral 
ventricle, you will come first to the so-called " egg-shaped middle 
point" (centrum semiovale Vieussenii) ; press this gently with the 
finger and you will find a yielding point which, when incised, opens 
into the lateral ventricle. Follow the finger with the knife and slit 
open the roof anteriorly and posteriorly. Look for a collection of 
fluid, and examine the choroid plexus, corpora striata, horns of the 
ventricle, and median septum. This is seized in the middle, raised a 
little, sectioned transversely, and thrown back, the connections holding 
it to the peduncles being severed. Now carefully insert four fingers 
into the transverse fissure and raise the posterior lobes in order to 
expose the corpora quadrigemina, optic thalami, pineal gland, and 
middle choroid plexus. By separating the two thalami a little, you can 
divide the commissura mollis and see into the third ventricle. 

To remove the brain, support the skull upon the incisors in such 
a position that the condyles look upward and the brain would fall out 
if it were free. Into the space thus obtained between the medulla and 
the base of the skull, insert a finger, the closed scissors, or the handle 
of a scalpel, and sever the nerves one by one as they appear. The 
olfactory bulbs, which are unusually large in comparison with those 
of man, are worked out from the ethmoidal depressions by a circular 
thrusting motion of the handle of the scalpel. When they are all sepa- 
rated, the brain will fall into the waiting hand, which must steady it 
constantly or the olfactory bulbs would be torn away by its falling 
out too soon. 

After the brain is removed, the inferior surface is first examined ; 
then, turning the brain over, the cerebellum is cut into halves. Expose 
the fourth ventricle and incise the floor longitudinally. With a thin- 
bladed knife cut radially to the cortex and transversely to the crura, 



POST-MORTEM EXAMINATIONS OF THE LOWER ANIMALS 423 

making numerous narrow incisions to detect the presence of any small 
hemorrhage or other lesion. 

Removal of the Spinal Cord. — This requires much time and 
labor when properly done, but is managed in various ways. But little 
time is spent in routine work when you have a butcher to assist you. 
The animal is suspended and the vertebrae are split off from their 
bodies by a hatchet; when this is cleverly done, the line of cleavage 
being kept a little to one side, the cord is but slightly injured. It is 
better, however, to proceed as follows : Saw off the ribs at their angles, 
separate the ilium from the sacrum, and clean off all the flesh. Laying 
the spine upon the table, begin at the pelvis and chisel off the vertebral 
arches, remembering that two chisels are necessary, one for each side, 
as the two instruments have different curves (Fig. 38). If an ordi- 
nary chisel is used, the arches should be partially sawed through to 
make their division easier. The hand holding the chisel supports itself 
on the spine, and the chisel is held as flat as possible while an assistant 
grasps the spinous processes and springs the arch apart. You may 
also expose the spinal canal ventrally by sawing through the vertebral 
bodies and arches on one side only. Section the nerves at their points 
of exit laterally to the intervertebral ganglia and lift out the cord 
enclosed in its membranes. Cut open the dura with the scissors and 
section the cord transversely with a sharp, thin knife. 

Exposure of the Accessory Sinuses. — To expose the nasal 
fossae saw the head in two, after removing the brain, a little to one 
side of the median line so as not to injure the septum on either side. 
These fossae may be sectioned transversely or their walls chiselled away 
to show the accessory sinuses. Csokor saws through the osseous struct- 
ure of the nose transversely from the level of the malar or lachrymal 
bone to the roots of the molars; a section is then made horizontally 
beginning at the anterior nares and joining at the first section (Fig. 
192). On raising this cap you have the maxillary, nasal, and frontal 
fossae well exposed. 

One or two long bones should be sawed through to judge of the 
condition of the bone marrow. 

Postmortems on Ruminants. — There are certain peculiarities 
in the skulls of ruminants which must be remembered when exposing 
the cranial cavity. It is only in very young animals that the cranial 
bones possess diploe, and in necropsies on hornless cattle the incisions 
are the same as for horses. On account of the prominent crests, which 
fall away very abruptly, and because a calf's head is somewhat rounder, 



424 



POST-MORTEM EXAMINATIONS 



the sawing will have to be clone in more numerous segments, and great 
pains must be taken on account of the thinness of the bones. The older 
the animal, the larger are the hollow places between the internal and ex- 
ternal plates; the diploe disappears and only a few crusts and plates 




Fig. 194. — Lines used in sawing in order to expose the cranial and nasal cavities in a ruminant. 

of bone interrupt the hollow spaces. The lateral and posterior portions 
of the skull are very prominent because of two large crests. The 
transverse section is nearly coincident with the posterior border of the 




% 



^2^» 



: w~ 



%J^>*-.^ ■ 



Fig. 195. — Appearance of cranial cavity of a cow after removal of the bony vault. 

superciliary ridges. The lateral sections are made in two segments, 
beginning at the ends of the transverse frontal incision and passing 
back over the temples to the foramen magnum. Clement has devised 
a better method (Figs. 194 and 195). First clear away all that part 
of the calvarium formed by the frontal eminence and the lateral 
depressions by sawing through the skull in a line passing from just in 



POST-MORTEM EXAMINATIONS OF THE LOWER ANIMALS 



425 



front of the horns obliquely backward and downward to the condyles 
or foramen magnum. After removing this plate of bone the whole of 
the posterior portion of the brain is exposed. Next make a transverse 




Fig. 196.— Second method, showing the lines of sawing in the removal of the brain of cattle. 

incision on a level with the superciliary ridges across the anterior end 
of the cranial cavity. Finally make two short longitudinal incisions, 
one on each side, about three centimetres from the median line; with 




Fig. 197. — Second method of opening the cranial cavity in cattle. 

mallet and chisel remove the oblong piece enclosed, and the whole 
brain is exposed. The curved horns of a sheep or a goat serve as 



426 POST-MORTEM EXAMINATIONS 

convenient handles for removing the calvarium and may very well be 
left on, while the horns of neat cattle should be knocked off. 

Another method for the removal of the brain in ruminants is 
that of Martin. The lines for sawing are well seen in Fig. 196. Care 
must be taken in the sawing that the brain is not injured. After the 
sawing is completed, the horns are hit apart with an axe, and the brain 
is exposed as in Fig. 197. 




Fig. 198. — Post-mortem examination of a sheep, a, rectum; b, pancreas; r, gall-bladder; d, caecum; 
e, abomasum (fourth or principal ruminant stomach). 

Postmortems on Swine. — With the body lying on its left side, 
the right extremities are removed, the abdomen is exposed by longi- 
tudinal and transverse incisions, the diaphragm observed, and the 
lateral thoracic wall divided by cutting with the bone-shears or sawing 
through the angles of the ribs and severing the cartilages close to the 
sternum. To remove the abdominal contents, first find where the 
duodenum is attached to the rectum; sever the duodenorectal liga- 
ment, separate the pancreas from the mesentery, and section the duo- 
denum. The anterior root of the mesentery is loosened by working 
it free with the hand and pulling on it, then sectioned, the whole of the 
mesentery excised from before backward, and the rectum divided 
Now cut away the spleen from the stomach, examine the opening of 
the bile duct, section it and the oesophagus, and separate the stomach 
from the diaphragm, leaving the liver freed from its suspensory liga- 
ment. The thoracic and cervical organs are removed as with other 
animals. 



POST-MORTEM EXAMINATIONS OF THE LOWER ANIMALS 



427 



In old quadrupeds the brain lies very deep, because of the immense 
air-spaces in the cranial bones which surround the brain on all sides 
except the temporal region. The transverse section is made a full 
thumb's breadth above the superciliary ridges (the eyes being first 
removed) and the lateral sections run back to the occipital foramen. 







Fig. 199. — Postmortem of the dog. Double lines show places at which the intestines are to te tied ; the 
dotted line indicates the direction for incising the mesentery. 

Instead of a transverse section we may make two oblique ones, begin- 
ning at the posterior border of the frontal process and joining each 
other and the lateral incisions in the anterior frontal region. 

Postmortems on Dogs, Cats, and Sheep. — The necropsy of a 
dog is easily made in either the dorsal or the left lateral position. 



428 POST-MORTEM EXAMINATIONS 

The procedure is the same as for the horse, but it is not necessary 
to remove the extremities entirely or to take off the hide; simply cut 
through the muscles enough to allow the limbs to fall away a little 
and the body will be sufficiently steady. (Figs. 199 and 200.) The 
thickening at the junction of the cartilages with the ribs is easily felt, 
the articulations are cut, and the sternum is pushed upward and for- 




,y 



Fig. 200. — The left ramus of the mandible has been removed and the tongue pulled outward and down 
ward, thus exposing the oral and pharyngeal cavities in a dog. 

ward after freeing the pericardium and the pleura. Section the 
tracheal vessels and oesophagus at their entrance into the thorax and 
remove the thoracic organs. 

The removal of the abdominal contents of a dog is easy. Divide 
the rectum at the pelvis and the two mesenteric roots, and the abdomi- 
nal aorta and inferior vena cava behind the liver; thrust the hand in 
between the liver and the diaphragm, and with scissors section the 
suspensory ligament of the liver, the vena cava, and the oesophagus 
after it is pulled down from the diaphragm and tied off or compressed 
with the fingers. All the abdominal contents may now be removed 
together. Spread them out, examine each again, test the patency of 
the bile ducts, and straighten out the bowels. It is, however, better 
first to remove the intestine, which is sectioned through the duodenum 
at the pancreas and through the rectum at the pelvis. Next either 
remove the liver with the stomach or after inspecting the bile ducts 
cut away the stomach from the oesophagus and duodenum and then 
remove the liver. 



POST-MORTEM EXAMINATIONS OF THE LOWER ANIMALS 429 

To expose the cranial cavity we have the same three lines as usual, 
the transverse section lying directly posterior to the rudimentary super- 
ciliary ridge, crossing the frontal sinuses and the anterior lobes of the 
brain. The anterior temporal and the parietal bones are not thick and 
contain diploe, so that the sawing must be carefully done. Since the 
petrous portion of the temporal bone has deep impressions upon its 
internal surface, in which convolutions of the cerebellum lie, and since 
the bony processes project from the adjacent bones, great care must 
be taken not to tear the cerebellum. In small dogs with round heads 
the line for sectioning is more nearly a circular one. 

The postmortem of a cat is made in the same way. I have seen 
diphtheria, tuberculosis, Trichina spiralis, and possibly scarlatina in the 
cat. 

The postmortem in the case of sheep is seen pictured in Fig. 198. 

Post-mortem Examination of Birds. — Plug up the nostrils, 
mouth, and vent with cotton; make an incision from the point of the 
breast-bone, or a little above, backward to and through the anterior 
portion of the anus, leaving the uropygium (pope's nose). Loosen 
each leg to the knee (above the femur) by tearing the soft parts with 
your thumb and fingers, then cut with a knife until they meet around 
the" pelvis at the rump. With your thumb-nail work the wings loose, 
hold the skin firmly, and, pressing your nail towards the body, cut off 
the wings at the elbow. To get at the brain make a V-shaped slit with 
its apex towards the median line at the foramen magnum, running 
up towards the centre of the skull ; the brain is then removed attached 
to the cord, and the skin is kept whole for taxidermic preservation. 
The " wish-bone" of birds is the joined clavicles. 

Post-mortem Records. — Kitt suggests the following scheme for 
the more intelligible recording of the findings in postmortems on the 
lower animals. 

RECORD OF NECROPSY. 

Species Sex Age Color of hair Owner 

Clinical history Treatment Mode of death Date of death 

Necropsy performed by Where performed Date 

Order of Persons present 

A. — External Examination. 
Position of the cadaver (on back, right or left side, hanging) 
Nutritional condition (weight) 
Removal or absence of parts 
Rigor mortis 



43 o POST-MORTEM EXAMINATIONS 

Condition of the skin and its appendages (the skin around the head, trunk, and 
extremities ; the horns, claws, hoofs, ears, scrotum, prepuce, udder) 

The natural body openings and visible mucous membranes (the discharge of foam, 
fluids, and excrementa ; the color of the lips, nasal mucous membranes, con- 
junctivae, anal and vaginal mucosae) 

B. — Internal Examination. 

Facts obtained in removing the hide 

Condition of subcutaneous tissues, fat, lymph-nodules, vessels, extravasated blood, 
muscles, ligaments, tendons, fascia, joints, and bones 

Abdominal and thoracic data 

Condition of diaphragm, position of organs, appearance of peritoneum, mediasti- 
nal and costal pleurae, and pericardium 

The oral cavity, tongue, teeth, soft and hard palate, salivary glands, pharynx, Eu- 
stachian tubes, oesophagus, retropharyngeal and laryngeal lymph-nodules 

The larynx, trachea, thyroid, and surroundings 

The lungs, bronchi, bronchial lymph-nodes 

The pericardial sac, heart, and thoracic vessels 

The liver and bile ducts, portal vein, and periportal lymph-nodules 

The spleen (capsule, pulp, trabeculae, Malpighian bodies, and vessels) 

The stomach and crop 

The pancreas ; the large and small intestines 

The mesentery, omentum, posterior aorta and its branches, and vena cava 

The kidneys, adrenals, ureters, capsule and pelvis of the kidney, and its half 
section 

The urinary bladder, urethra, and accessory sexual glands 

The pelvic portion of the rectum 

The genitalia : uterus, vagina (pregnancy, fetal membranes, embryo) ; or the 
male genitals 

The cranial cavity and the brain : calvarium, sinuses, cavities at the base of the 
skull, dura, cerebral superficies, ventricles, gray and white matter 

The eyes ; the middle and internal ears 

The fourth ventricle and the spinal cord with its membranes 

The nasal fossae and accessory sinuses 

The udder and supramammary lymphatic nodules 

The bone marrow 

Microscopic and chemic report 

Inspection of Special Organs. — The essentials for diagnosis 
which are to be looked for and recorded are about as follows : i . Name 
of the organ; from what animal; whether it died or was killed; 
whether the organ was entire or fragmented; whether , parts, lobes, 
etc., have been amputated; and if there are any adhesions to adjacent 
parts. 2. Weight. 3. Length and breadth of the part. In the ab- 
sence of a tape measure we may ascertain these dimensions approxi- 
mately by comparison with the breadth of the hand and the length of 
the finger. Every person should know the length of his index-finger, 
which is usually about ten centimetres and may be used to measure 



POST-MORTEM EXAMINATIONS OF THE LOWER ANIMALS 



431 



organs, pathologic spots, streaks, canals, etc. 4. Surfaces: whether 
smooth, even, wavy, granular, corrugated, rough, transparent, or 
cloudy. Color of the surface: general and primary color, special 
deviations and shades. The external contour of the organ and any 
prominences, with especial reference to their size as compared with 
grains of sand, millet-seeds, lentils, peas, beans, hazel-nuts (or filberts), 
a pigeon's, a hen's, or a goose's egg, the fist, the thickness of a child's 
arm, a child's head, etc. (Plate II.) 5. The consistence as deter- 
mined by palpation: soft, elastic (like the lungs), doughy, splenified, 
hepatized, tough, inelastic, carnified, indurated, leathery, like the kid- 
neys and skin, as hard as wood, cartilage, bone, or stone. 6. Section- 
ing of special parts : through the compact, so-called parenchymatous 
organs (muscles, liver, kidneys, lungs) large dissecting incisions are 
made. Through the brain and heart sections must be made in a certain 
way in order properly to expose certain cavities. On sectioning notice 
the resistance of the tissue, whether it cuts easily or is tough and pulls, 
whether the knife creaks as it goes through, whether the tissue is so 
hard that a saw is necessary, and observe if any fluid follows the sec- 
tion or if there are any abnormal contents. The surfaces of the section 
must be noted, their color, thickness, consistence, fluidity, and vascu- 
larity, as well as any other peculiarities which may be present. The 
pathologic diagnosis is made by considering the details gained in this 
way, which lead to one conclusion and exclude another. A gross ana- 
tomic diagnosis is often only provisional and dependent upon micro- 
scopic and chemic confirmation. 



CHAPTER XXVI 



PLANT PATHOLOGY 



While the Bible and earlier writers describe many diseases of 
plants, such as wheat rust, fig blight, and insect galls, plant pathology 
and the scientific treatment of parasitic diseases may be said to date 
from the beginning of the nineteenth century. The rapid spread of 
the potato bug (1859) m this country and the downy grape mildew 
in Europe (1878), directed attention anew to this subject. Millardet's 
Bordeaux mixture of copper was the cure found for the rust and Paris 
green for the potato bug. The San Jose scale imported from China, 
where it is said to have a natural enemy, has spread from the Pacific 
to the Atlantic, while the asparagus rust has extended in the opposite 
direction. 

The life history of plants is identical in many of its phases with 
that of animals, but vegetable morphology is easier of interpretation 
than that of animal structures. As bacteria are regarded as vegetable 
organisms, bacteriology is properly a branch of plant pathology. Plants 
are subject to some diseases that closely resemble maladies occurring in 
man, some of which appear to yield to similar treatment ; thus, chlorosis 
of plants, like certain microscopic diseases of apples and pears, is best 
treated by burying scraps of iron near the parent root. The influence 
of heredity and natural selection is well marked in plants. The 
younger Darwin has recently endeavored to demonstrate natural selec- 
tion in inanimate matter (rocks), and the ultimate result of these 
studies will doubtless add much to our knowledge of pathology. 

The growth and evolution of plants are modified by climatic condi- 
tions, temperature, humidity, and diathermancy of the air. Sudden 
changes of temperature, protracted heat or wet, and excessive or 
deficient precipitation not only affect the normal growth of plants, but 
may cause disease either directly by action on the plant itself or indi- 

1 For literature, see section of " Vegetable Pathology" in the current numbers 
of the Index Medicus and in the forth-coming volume of the second series of 
the Index Catalogue; Smith's Bacteria in Relation to Plant Disease, no. 27 of 
the Carnegie Ins. Wash. Publ., 1905 ; and Stevens, Science of Plant Pathology, 
Pop. Sci. Monthly, 1905, vol. lxvii, p. 399. 
432 



PLANT PATHOLOGY 433 

rectly on the soil. Judicious transplantation may save an ailing plant, 
or ill-advised change of soil or climate may cause a hearty one to perish. 
Transplantation also favors the extension of diseases. Unhealthy' soil 
is also a fruitful source of disease. In the presence of bacteria Legn- 
minosce are capable of utilizing the free nitrogen of the air by building 
it up into organic compounds. x It would seem that possibly some of the 
newer elements of the air, which are present in small quantities, may be 
needed for this reaction, and that the gas itself is not used up, acting as 
a catalyte; just as, theoretically, a small amount of sulphuric acid can 
convert a large quantity of starch into glucose. 

The analogies presented both in health and disease between plants 
and animals — the borderland between which is growing each year 
more and more difficult to define — offer a most promising field for 
scientific investigation. Among the many interesting subjects for 
study in the field of plant pathology may be mentioned trauma, 
mechanical and produced through the agency of insects, etc. ; the effect 
of anaesthetics upon plants; the influence of colored light upon the 
growth and development; heredity, as shown by the experiments of 
Mendel and Burbank; the dissemination of diseases by insects and 
parasites ; the study of plant diseases, as ergot and galls, for discovering 
remedial agents ; the killing of adherent spores of disease by formalde- 
hyd gas and other disinfectants without preventing subsequent germin- 
ation ; the analogy of plants affected by bacteria with animals affected 
by animal parasites; the comparative action of bacteria upon wild 
and cultivated plants, as in the case of ginseng; the mutation of 
species as studied by de Vries; an investigation of cabbage club-foot, 
an infection analogous in so many ways to cancer that it is supposed 
by some to be identical ; and the study of organisms similar to the 
Cory neb acterium tuberculosis and the colon bacillus, found upon grass. 

1 Science, October 27, 1905, p. 527. 



CHAPTER XXVII 

THE TEACHING OF POST-MORTEM TECHNIC AND THE INTERPRETATIONS 
TO BE DRAWN FROM THE MATERIAL SO OBTAINED 

In the ideal teaching of post-mortem technic there should be a well- 
equipped autopsy room, an abundance of material, 1 and a small class 
(not more than fifteen) of students well trained in anatomy, including 
histology and embryology, physiology, and physical diagnosis. The 
teacher should be one who is experienced in the practice of medicine, 
and in gross pathology, so that he is capable of drawing correct inter- 
pretations from the parts under consideration. The physical signs 
elicited during life should be explained by the pathologic lesions 
found, — e.g., cavities present in the lung, lobar pneumonia, pleurisy, 
carcinoma of the stomach, typhoid ulcers, cirrhosis of the liver, gas- 
troptosis, etc., may well be used to impress on the mind of the student 
not only their morbid appearances, but also lessons in diagnosis, 
symptomatology, and treatment. The student would thus gain more 
and would certainly be more interested in autopsies than in any other 
way by easily associating in his mind pathologic conditions with the 
physical signs and symptoms to which they ordinarily give rise. When 
practicable, the disease should have been studied during life by the stu- 
dent under the guidance of a competent physician or surgeon. The 
teacher should never forget to contrast the normal tissues with the ab- 
normal. The material for postmortems should not be drawn from one 
source, but from many. In my experience I have found an entirely 
different set of pathologic pictures in the different hospitals of Philadel- 
phia; for example, in the Presbyterian or University Hospitals, where 
a large number of pay patients are treated, the frequency and the char- 
acter of certain pathologic lesions are not the same as those seen in the 
Municipal Hospital, where contagious diseases are treated, and Blockley, 
where the scum of the earth die. In the Coroner's work the material is 
markedly different from that found, for example, in an insane asylum 
or the Institution for Feeble-Minded Children at Elwyn. Again, the 

1 In case bodies are not to be had, animals can always be secured. Indeed, 
there is a wider field for investigation in animals to-day than in the human body. 

434 



THE TEACHING OF POST-MORTEM TECHNIC 435 

Pennsylvania Hospital, with its large number of foreign-born patients, 
will show marked differences in the character of its autopsies to those 
made at the Woman's Hospital, the West Philadelphia Hospital for 
Women, or the Children's Hospital. 

To cover the ground of post-mortem technic in our medical colleges 
no less than ten hours of demonstration are needed by the one in 
charge and no less than six complete postmortems should be made by 
the student, and there is no end to the number of postmortems that can 
be seen with benefit by the student, especially if he has had an oppor- 
tunity of following the fatal illness or of having seen the patient some 
time previously during life. In the teaching of autopsies to me the most 
striking feature is the lack of anatomic knowledge of a practical nature. 
Thus, many students after passing their examination in anatomy are 
unable to tell the difference between a kidney and a spleen, though they 
will talk most learnedly about the Malpighian bodies and the loops of 
Henle. 1 The greatest place in the world for following the patient 
throughout the entire course of the disease is in Vienna, and it is for 
this reason that each year so many Americans go abroad. There, for 
example, Gohn will, with his assistants, in the morning make the 
autopsies, which are free to all, and in the afternoon demonstrate the 
specimens to a private class of twenty at a gulden apiece. The interval 
has afforded him sufficient time to prepare frozen sections and also 
gives him an opportunity of regulating his course so that the entire 
subject of gross morbid anatomy will be fairly well covered in the 
course of fifteen or twenty demonstrations; and it is surprising how 
frequently the autopsies run in certain directions; thus, one day the 
autopsies may reveal various examples of liver disease, while at another 
time, there may be a predominance of gastric lesions. In a separate 
but adjoining room Kolisko will be found to be investigating the cause 
of death in medicolegal cases, one of the most important and exacting 
departments of post-mortem examinations and one. too frequently not 
touched upon by the autopsist owing to lack of familiarity with this 
subject. 

1 See article by the writer in Medical News, 1898, vol. lxiii, p. 262. 



CHAPTER XXVIII 

MEDICOLEGAL SUGGESTIONS 

Although a physician is not expected to have a profound knowl- 
edge of legal matters pertaining to his profession, yet every doctor 
should be more or less familiar with the medical laws of the State or 
country in which he is practising. He should be well acquainted with 
the regulations of the Board of Health, of the Coroner's office, and 
of the criminal courts, and do all in his power to aid in their rigid 
enforcement. A synopsis of such laws and regulations is usually 
readily obtainable in book form, and nearly every physician has among 
his patients or friends a lawyer who is glad to discuss legal questions 
in return for medical information. Some of the salient points relating 
to medicolegal investigations and autopsies will here be briefly con- 
sidered, though many references to these matters will be found else- 
where throughout this work, especially in Chapter XXIX. 

Obligations of Physicians to their Patients. — The obliga- 
tion of a physician to society in the practice of medicine is in a certain 
sense voluntary. His is the right to refuse any and all cases that may 
apply to him for treatment or advice. Services once begun, however, 
he must, after giving notice of his intention to discontinue them, allow 
his patient reasonable time to fill his place, as otherwise he renders 
himself liable for damages. This obligation is equally binding in 
the case of charity patients. Contracts between a physician and a 
patient may be either express or implied. An express contract is where 
services are rendered in accordance with a definite agreement previ- 
ously entered into between the parties. There is the promise of 
proper treatment in an implied contract just as there is the promise of 
payment. Generally, however, the contract is implied by the law 
from the fact of employment and consequent attendance. Both forms 
of contract are equally binding, and both are subject to public policy. 
Contracts making the payment contingent upon successful treatment 
are valid, but, should the patient fail to follow the doctor's directions 
or to give him sufficient opportunity for treatment, the Court would 
probably allow the latter reasonable compensation. If the physician 
fail to exercise ordinary skill, he renders himself liable for malpractice. 
436 



MEDICOLEGAL SUGGESTIONS 437 

In law malpractice consists in the failure to possess or use such ordi- 
nary knowledge or skill as is generally possessed and used by physi- 
cians and surgeons in similar localities, whereby injury accrues to the 
patient. The term is also applied to acts which are expressly forbidden 
by statute. The average physician is not obligated to exercise the 
highest expert skill nor is his implied contract one binding him to 
effect a cure; he must simply treat the case with reasonable skill, dili- 
gence, and faithfulness. That done, he cannot be held accountable for 
results. Births, deaths (with their probable cause), and infectious 
diseases are to be reported to the proper authorities for registration. 
In hiring a wet-nurse for a syphilitic child the woman must be informed 
of the fact that the infant is specifically infected and of the risk that she 
runs in taking it to nurse. It is a criminal offence to practise medicine 
or surgery while intoxicated. 

The obligations of a patient to his physician, in so far as they 
relate to the treatment given, are more or less vague. They cannot 
be exactly defined. The patient should conform to the directions given 
him, but no legal liability arises if he does not : the risk is his. If in 
such circumstances the attending physician is of the opinion that his 
advice is being disregarded, to the detriment of his patient and perhaps 
of his own reputation, he is always at liberty to withdraw from the case 
and to request that another physician be called in. 

As to the physician's compensation, it may be stated that in the 
absence of a special contract the measure of the liability of the patient 
to his physician is the customary charge made by others of equal stand- 
ing for similar services. The question of compensation is a broad one 
and its full treatment is beyond the scope of this work. It may be 
remarked, however, that the specialist should protect himself by an 
express contract. Physicians should also be careful to have their 
accounts so kept as to be able to use them as evidence if dispute should 
arise. Much trouble and loss are frequently caused by neglect in the 
entries made by physicians in their books. In the case of Lafnn vs. 
Billington, the Appellate Term of the Supreme Court of New York 
held that a contract by a physician to give expert testimony for the 
plaintiff in a personal-injury case and to receive as his pay therefor a 
percentage of any amount realized is invalid. 

Expert Testimony. — No Court can compel a physician to give 
expert testimony, to make autopsies, or to conduct laboratory investi- 
gations without his consent, but any knowledge which the doctor may 



438 POST-MORTEM EXAMINATIONS 

possess pertaining to an individual criminal case must be given to the 
Court in the same manner as if he were a lay witness. His scientific train- 
ing is, however, his own personal property, the result of many years' 
study, careful research, and expenditure of money, and he is entitled to 
commensurate remuneration for the use of his knowledge as an expert. 
For the good of society, any facts pertaining to a given criminal case 
which are known to him should be freely and willingly given to the 
Court, though he thereby may be put to considerable loss of time and 
money. The expert should be cautious in expressing opinions before 
the case is called for trial. (Wormley.) Thus, in the Williams case, 
tried in Philadelphia in 1903, I was asked by the District Attorney 
while on the witness stand if I had ever expressed to the attorney 
for the defence an opinion as to the cause of death, and, if so, what 
that opinion was. The recent (1905) health census of New York City 
raises some interesting questions as to the power of compelling persons 
to answer certain questions for mere statistic purposes. 

That the Court can compel a physician to divulge professional 
secrets is an undecided point. In some States and countries such con- 
fidences of the patient are held sacred, as are the relations between 
legal counsel and client; while in other places (wrongly, we believe, 
in civil cases, but rightly in first-degree criminal cases) they must 
be divulged to the Court should questions pertaining to the same be 
asked the physician while on the witness stand. The matter is one 
for the Court to decide, and such decision, being given, absolves the 
witness. Whether the prescription of a physician is a privileged com- 
munication or not is a matter of much debate, the weight of opinion, 
probably, being that it is not. 

An expert is one who by reason of his peculiar experience, special 
study and training, or the performance of certain duties, is competent 
to ascertain particular facts of a technical nature or to form an opinion 
or judgment upon them, such as could not be expected from -the judge 
or jury. No ordinary witness is permitted to express an opinion upon 
the facts as presented to him, as this is supposed to be the province of 
the members of the jury. Thus, in one of my cases, where infanticide 
was suspected, an iceman had found the dead body of a baby in an 
ash-barrel, and the Judge would not permit the finder to act as an 
expert in giving the approximate weight of the child, though it would 
seem that, on account of his frequent weighing of ice, he would be 
more fitted to give a correct estimate of the weight than many other 



MEDICOLEGAL SUGGESTIONS 439 

persons. The weight of the child (nine pounds) was desired as 
evidence that it was born at or near full term. 

The jury is required to arrive at a decision upon the points at issue 
from the facts proved before it, and hence must necessarily base its 
verdict thereon. Where, however, there arise in the case technical 
issues, matters involving special knowledge, regarding which persons 
in general are not qualified to reach a correct judgment, and where, 
therefore, the opinion of those versed in such knowledge is neces- 
sary to the formation of a proper verdict, experts are called to testify. 
In so doing they must frequently give their judgment upon matters 
often presented to them in the form of hypothetic questions. Such 
questions are presumed to be framed from the testimony already 
accepted in the case. Great care should then be exercised in testify- 
ing, especially as sometimes the ingenuity of counsel is used so to 
formulate the hypothetic question as to confuse the issues in the mind 
of the jury or to elicit from the witness an opinion contrary to his true 
interpretation of the statements. 

A medical man should refuse to testify as an expert unless he is 
thoroughly qualified for that duty. In no case should he go on the 
witness stand without being as fully informed as is possible on the 
subjects on which he is to be examined, nor should he allow himself 
to be questioned on subjects on which he is not prepared. He should 
be honest and candid with those securing his services before the trial, 
and, no matter what may be the consequences, his answers while on 
the witness stand must be made with absolute impartiality. Upon 
a suit for damages an expert may be held responsible for errors which 
he may have committed in the performance of his work. Thus, a 
chemist passing glucose as free from arsenic might have to pay 
damages should beer be made out of the glucose and arsenical poison- 
ing result therefrom. 

The medical expert should at all times confine himself to purely 
medical topics and never become involved with matters that will place 
him in the light of a lay witness, of a detective, or of an attorney, 
and he should carefully avoid acting as a champion of the parties 
who are paying for his services and of attempting to plead one side of 
the case. His language should be as free as possible from technicalities 
and be such as can readily be followed by the least educated of the 
twelve jurymen, many of whom are only too often, unfortunately, unfit 
for the performance of their duties. Some judges carry this plainness 



44 POST-MORTEM EXAMINATIONS 

of language to an extreme.- Thus, while acting as an expert in a 
murder trial, the writer was once requested by the Judge not to use the 
word " hemorrhage" in testifying, as this term was too technical for 
the jury to understand. I at once substituted " bleeding" for the 
objectionable word and proceeded with my testimony. A well-known 
medical expert on being once criticised by the Judge for being too 
technical in his statement of, " I incised the abdomen and the intes- 
tines protruded/' immediately changed it to, " I ripped open the belly 
and the guts fell out." When not absolutely certain of a point unhesi- 
tatingly acknowledge the fact; thereby harm and the possible jeopard- 
ing of a human life may be avoided. But when sure of your ground 
undeviatingly adhere to it. At the close of testimony, especially if 
long and exacting, an opportunity is almost always given to correct 
any misstatements which may have been inadvertently made, and to 
make clear the meaning of any dubious points of the original testimony 
which may have been clouded by the cross-examination conducted by 
the opposing counsel. 

Often too much is expected from the expert, as the following 
instance shows: While testifying as an expert in a country town on 
a case where the postmortem revealed beneath the left eye a small 
incision closed with two stitches, ecchymoses about the eyeball, and a 
fracture of the skull, the District Attorney and the Judge criticised 
me severely because I would only state that the man had died from 
hemorrhage of the brain due to fracture of the skull. They desired 
me to say that the man had been knocked down with the fist of a 
person who had a ring upon his ring-finger, and that in this manner 
the cut and the fracture had been produced. I admitted that they could 
have been made in that way, but would not declare, apparently much 
to their disappointment, that they were so caused. 

Medicolegal Postmortems. — The objects of a medicolegal post- 
mortem include the finding out of the cause and mode of death, the 
establishment of a corpus delicti, the determination as to whether a 
crime has been committed, and if so the discovery of a motive therefor 
and the exact nature of the process employed therein. In such legal 
investigations the pathologist should protect his reputation in every 
possible manner, and he ought to hesitate to make a postmortem with- 
out the presence of a witness, who should, if practicable, be a profes- 
sional brother. For ascertaining the cause of death a line of inquiry 
should be mapped out based upon a hypothetic or tentative diagnosis 



MEDICOLEGAL SUGGESTIONS 44I 

suggested by the clinical history or special circumstances of the case. 
This may subsequently be corrected, modified, or abandoned as the 
autopsy proceeds, but the final diagnosis should, of course, not be made 
until the autopsy has been completed and any material requiring sub- 
sequent investigation reported upon by those undertaking this part of 
the work. The autopsic findings should be dictated at once to an 
amanuensis, and the record verified and signed upon its completion. 

The obducent should have an opportunity to view and examine 
the body before it is taken away from the place or position in which 
it is found, and especially before the clothes are removed. He should 
prior to the autopsy be put in possession of information as to the 
general, and also any special, circumstances of the case, and more 
particularly in regard to any injury or violence which the deceased 
may have received. He should also be advised as to any known disease 
or other condition which may have contributed to the death. No 
one ought to be allowed to witness the examination out of mere 
curiosity or unless specially authorized. The examination should not 
be commenced unless there is sufficient daylight in prospect to allow 
of the whole inspection being made without artificial light. All meas- 
urements should be accurately determined. Examine carefully the 
contents of the stomach to ascertain the length of time which has 
elapsed since the death occurred. Where the services of the obducent 
are called in by the law, he is freed from the necessity which exists in 
ordinary cases of obtaining the consent of the relatives of the decedent. 
One making a medicolegal autopsy is like a scout in the enemy's 
country : he never knows how and when he is going to get caught. 

In general the medicolegal post-mortem examination does not 
differ materially from the pathologic, except that in the former greater 
precautions are necessary in order to avoid sources of error or con- 
fusion, and that the cranial contents are examined before opening 
the large blood-vessels, as signs of congestion disappear after the 
severance of the aorta and venae cavae. Doubly ligaturing the oesopha- 
gus at the left of the trachea is a good routine practice, and it should 
always be done in cases of suspected poisoning. The urine collected 
from a cadaver is practically always albuminous. The importance of 
always examining the vertebrae cannot be too strongly insisted upon, 
as severe injuries thereof may exhibit no external signs of violence, 
while there may be other lesions found on the body which might 
otherwise be erroneously assigned as the cause of death. In some 



442 POST-MORTEM EXAMINATIONS 

cases after a most rigid and painstaking inspection no cause of death 
can be ascertained, but with care and systematic examination over- 
sights, inaccuracies, and mistakes will be reduced to a minimum. 

In case of suspected poisoning the primse vise should be tied at 
each end and removed. Double ligatures should then be applied at the 
junction of the duodenum and the ileum and at the end of the small 
intestine, dividing the viscera into three portions. The contents of the 
stomach and those of the intestines should be emptied into separate 
jars. Many poisons are extremely volatile and unless great care is 
exercised traces of them may be lost and justice defeated. 

Each organ should be received in a separate receptacle, and each 
receptacle should be marked, sealed, dated, and deposited where tam- 
pering with it would be impossible. The mouth of the receptacle 
should be so large that no injury will be done to the organ during its 
introduction. It is also well to remember that a tissue, owing to its 
fresh state, goes into a bottle more readily than it comes out, because 
of its being hardened by the preservative fluid. 

The form of report used by the writer in medicolegal cases is as 
follows : " I made a post-mortem examination of the body of Walter 
Foster on April 10, 1898, at St. Agnes Hospital, Philadelphia. The 
body was identified by George Bell, 636 Siegel Street, and Michael A. 
B ruder, 1847 Sartain Street, both of Philadelphia. I find that death 
was caused by shock and hemorrhage from stab- wound of the heart." 

While acting as Coroner's physician I rarely volunteered more than 
this information, but waited for the District Attorney to ask questions 
in regard to the nature of the wound and as to other facts of interest. 
By this method the jury is not confused by an enormous amount of 
irrelevant testimony, though the expert must be prepared to give, under 
cross-examination by counsel for the defence, the minutest details as 
to how the postmortem was performed. 

It may be remarked that there is a growing tendency to perfect 
and render more scientific the proceedings incident to and growing 
out of violent deaths. Courts have at times appointed a commission of 
physicians to examine into the physical condition of the plaintiff in 
personal injury cases. It has been suggested that in postmortems 
involving the question of crime the investigation should be carried on 
jointly by experts representing the State and the defendant; also that 
the question as to the cause of death shall be dissociated from that of 
the guilt or innocence of any particular individual and determined 



MEDICOLEGAL SUGGESTIONS 



443 



by a jury or commission of experts : but this brings us into the realm 
of speculation. We do not now confront such conditions. 

Autopsies on Infants. — The first question to determine in the 
examination of a babe is: was it born alive? If so, was it a full-term 
or a premature birth? If born dead, how many months of uterine 
gestation caused it to reach its present development, and after attain- 
ing its maximum growth was it carried as a foreign body in the uterus ? 

Determination of the Viability of a Child from the Post- 
mortem Appearances. — The reader is advised carefully to read 
Paragraphs 23 and 24 of Virchow's regulations for the perform- 
ance of medicolegal postmortems. (See Chapter XXIX.) To dis- 
cover the ductus arteriosus remove the thymus gland, incise the right 
ventricle along its septum, and extend the incision into the pulmonary 
artery along the middle portion of its anterior wall. The orifice is 
situated between and beyond the two openings of the right and left 
pulmonary branches. If the duct is open, a sound will readily pass 
into the aorta. It should be remembered that decomposition may 
produce bullae in the lungs, that the lungs may be distended by the 
forcible introduction of air in the methods used for artificial resusci- 
tation, and that air may get into the lungs of the child from emphy- 
sematous conditions affecting the uterus of the mother. 

If in the hydrostatic test the lungs float on top of the water, 
aeration is complete, — a strong proof of breathing at or after birth ; if 
they float beneath the surface, aeration is incomplete ; and if they sink, 
respiration is considered not to have occurred. Decomposition of the 
lung tissue may cause it to float. A very valuable sign of the viability 
of the child is the presence of uric acid crystals in the kidneys. 

Rigor mortis does not prove, as has sometimes been asserted, that 
the infant was born alive in the legal acceptation of this phrase. The 
rigidity may be of the so-called antenatal variety; it may even un- 
duly prolong labor by interfering with delivery. 1 

The Lancet of April 26, 1902, raises the query whether the dead 
body does not possess properties akin to radio-activity, and alludes to 
the photographs taken by Vignon and exhibited by him, with the wind- 
ing sheet preserved at Turin and traditionally said to be that of Christ, 
which seem to justify the belief that the human body is either radio- 
active or that it gives off vapors which exhibit a similar action to light 

1 Lancet, February 14, 1903, p. 460. 



444 POST-MORTEM EXAMINATIONS 

upon sensitive surfaces. Peroxid of hydrogen may be the main factor 
concerned. iV-rays of short wave length can be reflected, polarized,, 
and refracted, and are transmissible by a metal wire. Ballet has found 
the emission of these rays to be decreased in diseases of the cord, as 
myopathies and neuritis, and increased in diseases of the brain, as hemi- 
plegias and spastic paraplegias. Certain substances seem to store up 
these rays and emit them later. The question is whether there are 
not various rays of a similar nature. The conversion of radium into 
helium may also be of importance in this connection. Fluorescence 
and phosphorescence have also been much studied of late, and all these 
phenomena may have an important bearing on the future of pathology. 
An ion contains electrons. The Arrays increase the brightness of a 
spark, and phosphorescent bacteria may be used for detecting them. 
Sight, taste, smell, and hearing become more acute under their in- 
fluence. Chloroform applied to plants seems to hinder their produc- 
tion. The Comptes-rendus hebd. des seances de V Acad, des sciences,. 
1903-4, contains most of the best literature on the iV-rays. 

Post-Mortem Excitability of the Inhibitory Nerve Appa- 
ratus in the Mammalian Heart. — Locke a and Danilewsky 2 have 
recently made some interesting experiments with an aqueous solution 
of : Sodium chlorid, 0.9 per cent. ; calcium chlorid, 0.024 per cent. ; 
potassium chlorid, 0.042 per cent. ; acid sodium carbonate, 0.01-0.03 per 
cent. ; and glucose, o. 1 per cent. When passed through the coronary- 
circulation under the pressure of an atmosphere of oxygen, perfusion 
of a rabbit's heart twenty-four hours after death with this solution 
not only starts beats but also so revives the nervous structures that 
stimulation of the vagus causes inhibition. Three days after death 
the auricles may be made to beat. The most astounding experiment 
of all was that by Locke, who took an adult rabbit's heart which had 
been hanging in the laboratory for five days, and which when perfused 
with the above solution of 35 ° C. gave beats of sufficient strength to- 
give a tracing 2.5 mm. high. 

Period of Intra-uterine Gestation. — In deciding the period 
of intra-uterine life of the infant the external evidences of value 
are: (1) Length and weight of the child (for the dimensions and 
weights of the new-born see page 395 and 396) . (2) Conditions of the 



1 Zentralbl. f. Physiol., December 30, 1905. 

2 Archiv f. Physiol., 1905, Sup'l Band, p. 190. 



MEDICOLEGAL SUGGESTIONS 445 

skin and its appendages. In the healthy babe at full term the skin 
is white and covers the body smoothly; woolly hairs are present in 
perceptible numbers only on the shoulders; the hair of the head is 
from two to three centimetres long; the nails are hard and horny, 
extending beyond the ends of the fingers, but not of the toes. (3) 
Condition of the umbilical cord, which at term is fifty centimetres 
in length and is inserted somewhat below the middle of the abdomen, 
falling off by inflammatory demarcation on the fifth or sixth day. 
(4) State of the cartilages of the nose and ear, being hard in the 
mature infant. (5) Presence or absence of the membrana pupillaris, 
which disappears after the eighth month. (6) Condition of the 
genitals in both sexes; as descent of the testes begins at the seventh 
month, those of the full-term male should be in the scrotum. The 
female labia are generally found closed. (7) The measurement of the 
fontanels, of the cranium, and of the transverse diameter of the body 
at the shoulders and hips. (8) The size of the centre of ossification 
(Beclard's) in the lower epiphysis of the femur. To view this the 
leg is flexed on the thigh, a transverse incision is made below the 
patella, which is removed, and the femur is then exposed. Thin 
transverse sections of the cartilage are made until the greatest diameter 
of the centre of ossification, if present, is reached. The centre is 
absent before the thirty-seventh week, and in the child at full term 
has a diameter of from two to three lines, though it may even then be 
absent. If the diameter is more than three lines, the child has very 
likely lived for a time since its birth. (Reese.) The osteochondral 
line is also to be examined for syphilitic changes. (9) With but very 
rare exceptions, a full-term child presents in the inferior maxilla eight 
alveolar compartments completely separated the one from the others. 
(Vibert.) 

From the internal examination important evidence as to the age 
of the child, and especially as to respiration, is secured. Upon ex- 
posing the abdominal cavity, which is to be done before opening the 
thorax or cranium, the position of the diaphragm in its relation to 
the ribs is immediately noted, as especially urged by Virchow. If 
the lungs do not contain air or are but partially distended, the 
diaphragm reaches to the fourth rib; when the lungs are fully dis- 
tended, the diaphragm is at the fifth or sixth rib on the right and at 
the sixth rib or intercostal space on the left. 

To facilitate the examination of the umbilical vessels, Nauwerck 



44 6 POST-MORTEM EXAMINATIONS 

recommends a division of the usual abdominal incision, shortly before 
reaching the navel, into two diverging incisions extending to the 
pubes. The abdomen is opened, and the umbilical vein, made promi- 
nent by traction on the triangular flap, is traced along its course, 
ligated, opened with small scissors, and divided. Turning down the 
flap over the pubes exposes for examination the umbilical arteries to 
either side of the remains of the urachus. (Figs. 164 and 168.) 

Criminal Abortion. — Formerly abortion was not legally a 
crime if performed with the consent of the mother prior to the 
viability of the foetus. It was at one time not regarded as murder 
even to take the life of a child at any period of uterine gestation. 
The barbarousness and danger to society of this view were later 
recognized, both abroad and in this country, and various laws with 
different penalties attached thereto were enacted making it a criminal 
offence to practise abortion at any period of gestation, unless for the 
express purpose of saving life. (Witthaus and Becker.) 

There is no other class of cases so trying to the patience, ingenuity, 
and skill of the pathologist as those of abortion, which is accom- 
plished by numerous methods. Many respectable women expose 
themselves to cold, falls, and douches with the hope of relieving 
themselves of their offspring apparently by accident. Many pills 
and potions are sold to induce a resumption of the menstrual dis- 
charge, and one often finds them on sale in drug-stores of the first 
rank and openly advertised even in the religious press. These nos- 
trums are sometimes composed of poisons that may cause the death 
of a pregnant woman. Lead has recently been used extensively in 
England in order to produce abortion, and this toxic agent has been 
found in the organs of a child carried to term in a case where the 
abortion did not occur after the use of this substance. The use of 
instruments, especially the spiral douche advertised in so many papers, 
is a very common method of procedure. Indeed, the most successful 
criminal abortionists operate so that, unless through accident, no 
evidence of the operation is left. Usually all that can be found is 
evidence of a recent . pregnancy. When infection occurs it usually 
travels by means of the ovarian veins. Septic abscesses in the lungs 
are common and ulcerative endocarditis may occur. The five most 
frequent causes of spontaneous abortion are syphilis, alcoholism, the 
infectious fevers, endometritis, and diseases of the placenta, as apo- 
plexy. It must be remembered that, while there are generally accom- 



MEDICOLEGAL SUGGESTIONS 447 

plices in abortion, yet in many cases it is self-inflicted. The difficulty 
of distinguishing between the two is almost insuperable. All that the 
obducent can do is to use the utmost care in his examination and to 
note all the circumstances, with a view not only to the conviction of 
the guilty abettors, but also to clear, if possible, those unjustly accused. 

When violence is done to the child, the nature of the injuries 
must be carefully noted. When violence is done to the uterus, some 
form of infection usually follows. In examination care must be taken 
to exclude the possibility of previous disease of the uterus or adnexa 
as a cause of the infection or possibly as a cause of abortion. In 
former days, when curettage was more used than it is now in the 
treatment of abortion, an additional factor was added, making it diffi- 
cult and often impossible to distinguish dilatations of the os due to 
the instrument producing the abortion and to the passage of the foetus 
from those induced by the introduction of the curette and the sub- 
sequent packing with iodoform gauze. The vital history of the foetus 
should be compared with the physical condition of the mother, the 
history of the sexual life of the parents, specific disease, etc. 

Usual Causes of Death. — In Chapter XXX will be found a list 
of all the recognized causes of death, and it is recommended that this 
International System of Classification be used by every one in order 
that uniformity of nomenclature may be secured throughout the world. 
Sudden death is usually due to failure of the circulatory apparatus, to 
cessation of respiration, to disturbance of the nervous system, to 
deficient nutrition, to poisons either produced within the body or intro- 
duced from without, or to violence by physical or chemic forces, heat or 
cold, electricity, wounds, missiles, etc. 

Many conditions that have existed a long time may cause sudden 
death by overcoming the balance of life. Thus, in chronic nephritis 
uraemia may develop suddenly and cause death after only a very slight 
acute illness. Again, an aneurism may rupture without sudden in- 
crease in the symptoms or any violence, simply by a natural, slow 
progress of the lesion. All mortal diseases and many that by them- 
selves do not end fatally may contribute to the production of sudden 
death as well as to slower dissolution. 

No disease causing severe disturbance of heart, kidney, lung, 
nerves, or digestion can be ignored in estimating the factors that 
brought about the death of the patient. Certain maladies of common 
occurrence should be in our minds in making examinations, though 



448 POST-MORTEM EXAMINATIONS 

never so prominently as to prevent a proper search for other con- 
ditions. Thus, in children consider diseases acquired in intra-uterine 
life, malnutrition, accidents at birth, infection by the umbilicus, hemor- 
rhages, infectious diseases, pneumonia, enteritis, bronchitis, meningitis, 
congenital syphilis and other hereditary diseases, infectious fevers, 
malformations, etc.; in young adults, infections (local and general), 
violence, typhoid fever, and tuberculosis; in middle life, diseases of 
the lungs, kidneys, heart, and blood-vessels, hepatic and gastrointes- 
tinal conditions, infections, violence, occupation neuroses, pneumonia, 
tuberculosis, cancer, etc. ; in old age, nephritis, carcinoma, softening of 
the brain and heart, gall-stone formation, sarcoma, aneurism, cerebral 
hemorrhage, embolus, thrombosis, tumor or abscess, arteriosclerosis 
in its most varied forms, obstruction of the coronary arteries, heart 
lesions, etc. 

In Coroner's cases death very commonly results from heart ex- 
haustion, due, as the case may be, to intrinsic disease, to excitement, 
or to poisons. Care should be taken to determine the cause of this 
exhaustion, whether it was due wholly to heart disease, such as a 
valvular lesion, or to one of the exciting causes. In kidney con- 
gestions consider whether death was due to failing heart causing 
passive congestion, to poisons, or to inflammatory congestion, such 
as would be part of an acute nephritis. Ascertain if the oedema of 
the lungs is dependent upon cardiac, renal, or cephalic lesions or 
primarily upon a lung condition principally. 

Violent Death. — When there is doubt as to homicide, all the 
precautions necessary for such cases must be strictly observed. The 
sort of violence, its mode of application, and something of an estimate 
as to the amount, direction, and conditions of application of force can 
usually be made from post-mortem examination. In the inspection 
of wounds the condition of the tissues and the position and direc- 
tion of all lesions discovered are to be very carefully noted, as some- 
times the instrument with which they were inflicted may safely be 
inferred therefrom, and at times the findings will point to the cir- 
cumstances under which the injuries were received. A minute descrip- 
tion of the injuries is absolutely necessary, so that if called upon in 
court an exact account of them can be given. The amount of con- 
tusion, laceration, extravasation of fluids, and damage to any vessels 
must be carefully noted. It is important in gunshot wounds that the 
projectile should be found. About the wound of entrance look for 



PLATE VI 



t 



* 






-* 



> 






4- ^ 









PLATE SHOWING COMPARATIVE EFFECTS OF "BLACK" AND 
POWDER CARTRIDGES AT SHORT RANGE. 



SMOKELESS 



Figs, i, 2, 3, and 4 are produced by a revolver (.38 inch) charged with ordinary black powder and 
held in hand. The firing distance is eight inches. The markings were made before the members of 
the Academy of Surgery of Philadelphia on the evening of May 5, 1902. In Fig. 1 the hammer is up; 
Fig. 2, to the left ; Fig. 3, to the right ; Fig. 4, down. Fig. 5, revolver immovably held by fixing in a 
vice; bullet-hole in centre of brand; black-powder cartridge. Fig. 6, revolver cartridge of "smoke- 
less" powder, fired from hand ; hammer up ; showing circular powder mark, with little or no "brand" ; 
Fig. 7, same, hammer down. (The illustrations are about one-half natural size.) 



MEDICOLEGAL SUGGESTIONS 449 

powder marks, singeing, and smudge. If the projectile struck a bone, 
a splinter may have been detached and caused injuries not along the 
line of the main wound. The effect of small arms loaded with smoke- 
less powder has recently been studied by Johnson. 1 Such markings 
are less distinct and more indefinite than in the case of black powder. 
Even at a distance of three inches or less the markings may be so 
indistinct as to be capable of being wiped away from the skin with ease, 
and when the part is covered with clothing no powder marks are 
found nor is the clothing scorched. Herold 2 reports a fatal case 
where a pistol fired at short range left no powder markings of any 
description. Plate VI shows the effects of black and smokeless powder 
at short range. ( Brinton. 3 ) Death is frequently due to shock, which 
may result from a blow that leaves no mark visible at the post- 
mortem. This is quite uncommon. Injuries to the head make it 
necessary to estimate the structural and tensile strength of the skull 
in each case. When a fracture of the skull is found or suspected, the 
skullcap must be cut away with the saw only, not using the chisel. 
Contrecoup must always be considered in hunting for fractures and 
lacerations of blood-vessels. Rawling 4 has recently published an in- 
teresting article on the mechanism of skull fractures, and Wadsworth 5 
has discussed the question of injuries to the brain. Accidents of various 
sorts may produce most marked and varied deformities, and give rise 
to such interesting medicolegal questions as the following: What was 
the duration of life after the reception of the fatal injuries? Did an 
electric shock immediately kill the person, or, being only stunned, did 
he die from the effects of the fall? Did a woman whose decomposed 
body was found in water, with enough arsenic in her system to kill, die 
from the effects of the poison or from drowning? In a case where a 
man shot his wife and then committed suicide, which one died first? 
A most inviting field of research and of medicolegal dispute are cases 
of malignant tumors and of infection arising within the body from 
traumatic injury received externally. 

Suicide. — Upton, formerly of the Chicago Tribune and an author- 
ity upon suicide in America, says that during the last thirteen years, 

1 Annals of Surgery, 1904, May, p. 798, and June, p. 1006. 

2 Legal Medicine, 1902. 

3 Int. Clinics, Twelfth Series, vol. iii, p. 148. 

4 Lancet, 1904, April 9, p. 973, and April 16, p. 1034. 

5 Proceedings Phila. Path. Soc, February 28, 1901. 

29 



45 POST-MORTEM EXAMINATIONS 

1891 to 1903 inclusive, 77,617 suicides (57,317 men; 535 physicians) 
were reported as suicides in the newspapers of this country. 1 That 
the number of suicides, especially among children, is increasing 
throughout the world is undoubted, this being more notable in times 
of financial trouble. Up to the time of the Japanese war, suicide had 
not increased in Russia. Prior to 1894 the larger number of suicides 
shot themselves ; now such poisons as gas and carbolic acid are most 
frequently employed, arsenic not being used so often as formerly. In 
Chicago in 1902 there were 147 cases of self-destruction, 127 of which 
were by carbolic acid. In Philadelphia during the same year there 
were 196 cases, of which 42 were from gunshot wound, 33 from gas 
asphyxiation, 32 from strangulation, and 31 from carbolic acid. Ac- 
cording to Vibert, the order of frequency of suicides in France is 
by hanging, drowning, shooting, illuminating gas, and poison. In 
Germany a favorite method of committing self-murder in the army 
is to explode a blank cartridge in a rifle, the barrel being previously 
filled with water. 2 In a recent suicide in Philadelphia an insane patient 
at Blockley held a razor in each hand and gashed his throat in both 
directions. I have seen cases where a man cut his wife's throat and 
then his own, thus affording a favorable opportunity of comparing 
the wounds inflicted. Great care must be used in making deductions 
from such examinations, as well as in saying from the inspection of 
an incision whether it was made by a right-handed or a left-handed 
person. To prevent detection ingenious w T ays of hiding the effects 
of poisons upon certain parts are often tried. Thus, potassium bichro- 
mate may be introduced into the stomach inside of figs, a device which 
will prevent injury to the upper intestinal tract. 

During my term of service of nearly three years as Senior Coro- 
ner's Physician of the City of Philadelphia, I performed, according 
to the official records, 799 postmortems, of which 59 were homicidal. 
It should be remembered that there were two physicians for Phila- 
delphia, and that the Coroner's jury were able in many cases to render 
a verdict without a necropsy being made, practically no accident cases, 
no suicides from known causes, and no subjects accompanied by letters 
from a physician stating the probable cause of death undergoing such 
examination. Of persons " found dead" the bodies were too much 

1 In 1905 the number of deaths by violence reported was 9212, the homicides 
exceeding those of 1904 by 730. There were 133 executions in 1905 and 66 lynchings. 

2 London Times, July 30, 1903. 



MEDICOLEGAL SUGGESTIONS 451 

decomposed to permit of a proper diagnosis, some of them having 
been in the water for months or showing skeletal parts alone. Under 
the head of Bright' s disease and uraemia are included some cases of 
alcoholism or of deaths incapable of diagnosis post mortem without 
extended chemic or microscopic study, etc. All the victims of heat- 
stroke, with one exception, appeared to be alcoholics. 

The chief causes of death, arranged alphabetically, were : 

Abortion 33 Heat 9 

Abscess of various parts of the body 5 Hemorrhage from various causes 

Alcoholism : 45 other than extra-uterine, injuries, 

Aneurism 24 etc 16 

Apoplexy 28 Inanition 14 

Appendicitis 7 Injuries, as kick of horse, blows, run 

Bright's disease and uraemia 84 over by wagon, etc 16 

Burns and scalds 5 Meningitis, tuberculous, and spotted 

Cancer 12 fever 6 

Childbirth 3 Peritonitis from other causes than 

Cholera infantum 9 abortion and appendicitis 9 

Cholera morbus 5 Poisoning 56 

Concussion of brain 3 Scarlet fever 4 

Convulsions 7 Stab wound 8 

Croupous pneumonia 19 Strangulated hernia 4 

Cyanosis 8 Strangulation 7 

Diphtheria, including croup 11 Stillborn 15 

Drowning 50 Suffocation 9 

Electric shock 8 Syphilis 3 

Erysipelas 2 Tetanus 2 

Extra-uterine hemorrhage 4 Traumatic hemorrhage of the brain . 9 

Found dead 9 Tuberculosis of the lungs 16 

Fracture of skull 27 Typhoid fever 6 

Fractures, other parts 3 Miscellaneous 68 

Gunshot wounds 25 



Heart disease 76 Total 799 

The fifty-nine cases of homicide were made up as follows : 

Burns 1 Gunshot 18 

Drowning 2 Knife wound 10 

Injuries, as hemorrhage from fract- Poisoning (illuminating gas 2 and 

ure of the skull from a fall fol- strychnine 1) 3 

lowing a blow, etc 24 Strangulation 1 

The kind of poison used in the fifty-six cases was: 

Aconite 1 Chloroform 1 

Ammonia I Creosote 1 

Arsenic 5 Cyanid of potassium 1 

Carbolic acid 10 Ether narcosis 2 



452 POST-MORTEM EXAMINATIONS 

Hydrocyanic acid 2 Oxalic acid 1 

Illuminating gas 12 Phosphorus 1 

Lead 1 Silver nitrate 1 

Oil of mirbane 1 Stramonium I 

Opium (acute) 10 Strychnine 2 

Opium (chronic) 1 Sulphuric acid I 

Cases of poisoning are almost daily being reported from new 
sources, by novel methods of procedure, and from a constantly in- 
creasing number of unexpected causes. Thus, in flash-light photog- 
raphy the magnesium oxid and the chlorate of potassium may produce 
on ignition chlorin gas sufficient to inflict bodily harm. 1 A dye, para- 
phenylendiamin, used in the preparation of certain furs, may give rise 
to bronchial asthma and skin eruption. The use of thread to remove 
particles of food from the teeth may cause arsenical poisoning and 
the picking of the teeth with splinters of matches may give rise to 
phosphorus necrosis. Children playing with " tin" toys, and soldiers 
in whose flesh are embedded bullets may suffer from lead poisoning. 
Poisonous toxins are often produced in imperfectly cured fish. The 
spraying of fruit trees may occasion fatal poisoning by the material 
falling on vegetables below, such as salads and beet greens. Loffler 
calls attention to poisoning -by milk from cows that have eaten poi- 
sonous plants. Petroleum sprees, resembling old-time chloroform 
parties, are increasing, boys even stealing kerosene from the public 
streets for the purpose. Women smoke " tea" cigarettes and boys suck 
the cologne from automatic machines. The effects of poisons may be 
modified in many ways ; thus, the presence of insoluble substances 
may inhibit to a certain extent their toxic action. 

IS AN INTERCRANIAL HEMORRHAGE DUE TO VIOLENCE OR DIS- 
EASE; or is it a Combination of Both Factors? 2 — The usual situ- 
ations of a cerebral hemorrhage are : ( 1 ) Between the bone and dura 
mater; (2) Subdural of the arachnoid space; (3) Between the pia 
mater and the brain substance; and (4) In the substance of the cerebral 
matter itself. The situation of a cranial hemorrhage may be most varied, 
and it may be associated with capillary hemorrhages situated at a dis- 
tance from the effused blood. The first point to determine is the condi- 
tion of the arteries of the circle of Willis, following out with great care 
the middle cerebral artery. The signs of violence are of the greatest 

1 Graefe, Deut. med. Wchnschr., March 13, 1902, p. 191. 

2 Taylor's Principles and Practice of Medical Jurisprudence, 1905, vol. i, p. 500. 



MEDICOLEGAL SUGGESTIONS 453 

importance, and yet it is sometimes difficult to determine whether the 
violence has been produced first and the hemorrhage afterwards or 
the person has suffered from an apoplectic stroke and in falling 
has sustained the injury. Scurvy, purpura, sclerotic kidney, haemo- 
philia, and arterial atheroma are the most common causes of capillary 
oozings without a very definite easily observable blood clot. An evi- 
dent clot in the substance of the brain or in the ventricles is never the 
result of violence alone unless the violence has been sufficiently severe 
to leave manifest evidence of its infliction, but it is a very frequent result 
of disease alone or disease plus excitement. The younger the patient 
and the less inclined to intemperance, the rarer it is to find definite 
hemorrhage or capillary oozing in the substance of the brain without 
evident violence. But this may occur from no special cause or from a 
violent fit of coughing, as in whooping-cough. In difficult labor it 
is by no means uncommon. Meningeal hemorrhages are much more 
likely to be the result of injury than of disease. A meningeal hemor- 
rhage is found immediately under the spot struck or by contrecoup on 
the opposite side of the skull. In case of fracture the hemorrhage 
may occur anywhere in its neighborhood. When a cerebral hemor- 
rhage, no matter what its extent or seat, is associated with a fractured 
skull the presumption that it was due to violence is practically over- 
whelming. The age of the clot may throw light upon a difficult prob- 
lem. Excitement must be allowed to have its influence in giving an 
increased tendency to cerebral hemorrhage and in aggravating the 
quantity of effused blood, but no further. Recent effusions of blood 
are recognized by their red color and the consistency and appearance . 
of the clot. After some days the clot acquires a chocolate or brown 
color and this passes gradually into an ochre tint from twelve to 
twenty-five days after the violence. Old clots are firmer and there is 
much lymph which is sometimes disposed in membranous layers of a 
fibrous structure. The surface of the brain sometimes presents a 
mark indicative of pressure. 

One of the most common homicidal ways for the production of a 
fatal hemorrhage is for a man to be knocked down by another and 
in falling to strike his head with sufficient force to cause a fatal hemor- 
rhage of the brain, with or without a fracture of the skull. An extra- 
dural hemorrhage is most apt to be associated with fracture. Children 
dying from toxic doses of alcohol frequently show internal hemor- 
rhages of the brain. 



454 



POST-MORTEM EXAMINATIONS 



Burns and Scalds. — Burns are produced by dry heat and show 
when fresh no maceration of the tissues. When inflicted by intense 
heat or by flame, there will be found scorching or singeing of clothing 
and hair, and possibly of flesh. When resulting from contact with a 
hot surface, note especially the shape of the burn, and, if the alleged 
hot object can be obtained, a corresponding mark may be found 
upon it. In burning the hair often reddens. In burns from electricity 
the markings are apt to be branched. It must not be forgotten that 
burns and scalds, especially when preceded by an explosion, may cause 
considerable injury or even destruction of the parts. Scalds are pro- 
duced by vapor, steam, or a liquid, and usually show some trace of the 
action of the fluid on the mucous membrane or skin. In plain scalds 
singeing is absent, but where fire has followed an explosion both scalds 
and burns may be found. In such cases the mucous membrane of the 
air-passages should always be examined. In cases of scalds and burns 
the extent of the injuries must be determined both in breadth and in 
depth, with a careful observation of secondary changes, such as sepsis, 
internal congestions, and inflammations. There are probably produced 
by these means hsemolysins and hsemo-agglutinins, 1 which products are 
poisonous to the organism, and act as in other forms of auto-intoxi- 
cation. Death ensues when one-third of the body is burnt, even 
though but slightly, from shock to the nervous system, hyperpyrexia, 
and various circulatory disturbances. 

Death by Electricity. — In death by lightning the clothes are 
sometimes torn off the body and there sometimes occurs a peculiar 
form of burn, the so-called lightning figures, and a rupture of 
internal organs, as the liver or heart. In some cases the point of 
entrance or exit can easily be made out by marks upon the skin or 
burns in the clothes. The exit of the current is especially to be looked 
for in the heel owing to the presence of nails in the shoe. It is some- 
times most difficult to tell, in those cases where an electric shock has 
been received and the person falls thereafter, whether such a person 
died from the effects of the fall or from the electricity. There are no 
absolutely constant findings at the autopsies. There is often unnatural 
rigidity of the muscles, sometimes with distortion. There may be 
evidence of electrolytic action of the blood and organs, as in the brain 
and cord; there, signs of suffocation and hypervenosity of the blood 

1 Editorial, Jr. Amer. Med. Assoc, January 9, 1904, p. 103. 



MEDICOLEGAL SUGGESTIONS 455 

are found. Microscopically, degenerations are found in the gray 
matter of the spinal cord along with dilation of the central canal and 
hemorrhages. It would seem that death is most frequently due to 
paralysis of the heart or of the central pulmonary system. 

Jellinek * finds that the anatomic changes in the tissues resulting 
from the passage of a powerful electric current diminish the resistance 
of future currents. Mice are killed with a weak current, but pigs show 
the greatest resistance. Death by electricity occurs more quickly after 
administration of morphine or cocaine, but is retarded by chloroform 
anaesthesia. A dose of morphine might therefore be administered with 
benefit before an electrocution. A horse is more easily killed by elec- 
tricity than a man, and the alternating current is more deadly than the 
continuous current. 

Cases of death have been alleged to occur from cancer due to 
the X-rays. The Galway case, tried in the Dublin courts in March, 
1904, contains the best account on record of the legal liabilities, the 
case being decided for the defendants that the burn was not caused by 
negligence. As already seen Schonberg has shown that all the male 
rabbits and guinea-pigs exposed to the Rontgen rays proved sterile 
afterwards. Brown and Osgood have collected the records of eighteen 
cases of total azoospermia or oligonecrospermia in X-ray workers. 

Death from Heat or Cold. — After fatal heat-stroke the body 
is often very hot for hours and decomposition may be uncommonly 
rapid. There may be general internal congestion. It is usually 
necessary to know somewhat of the history of the case before a 
verdict can be rendered of heat-exhaustion, sunstroke, or thermic 
fever. In cases of death from cold we often find pallor or discoloration 
of the skin and congestion of the viscera with blood of rather bright 
color. No single characteristic lesion results from exposure to 
moderate excess of either heat or cold. When no pathologic lesions 
can be found, death is probably due to shock. Any chronic disease 
of the viscera tends to reduce the power to resist severe temperature 
changes. There is no significance in the freezing of the body beyond 
showing that considerable time may have elapsed since death. The 
frozen flesh of the mastodon sometimes found in the Siberian plains 
may be used as food, though it must be thousands of years old. 



1 Elektropathologie, Stuttgart, 1904. See also Bois; Arch, d 'electric, med., 
Bordeaux, 1903, xi, p. 608, and Kratter, Eulenb. Jahrb., ii, 1904 (lit). 



45 6 POST-MORTEM EXAMINATIONS 

There are no characteristic changes in sunstroke. Rigor mortis 
comes on early. Lividity and putrefactive changes develop rapidly after 
and even before death. Venous engorgement is extreme, particularly 
in the cerebrum. The left ventricle of the heart is contracted ; the right 
is dilated and may be full of blood imperfectly coagulated and deficient 
in oxygen. The blood is fluid, dark in color, acid in reaction, and prob- 
ably contains, as in burns, a poisonous substance which acts on the more 
highly specialized cells of the body. Petechial patches may appear in 
the subcutaneous and subserous tissues. The elevation of temperature 
is often remarkable, and it is extremely disagreeable to make an autopsy 
in these cases, as I have done, soon after death, with a temperature of 
106 F. In a case of mine of stramonium poisoning, with a tempera- 
ture of nearly no° F., the clinician had diagnosed sunstroke, because 
of the high temperature and lack of history afforded by the patient. 

Infanticide. — Many methods have been resorted to, as exposure 
to cold, smothering in various ways, strangulation either by the hands 
or by a ligature around the neck, and wounding with various instru- 
ments, sometimes accompanied by efforts to conceal the act. The 
child may be intentionally drowned in a vessel containing fluids 
discharged from the vagina at the time of birth. Gross violence or 
poisons may be employed. 

Death by Starvation. — There is usually extreme emaciation, 
which is shown especially by a sinking of the eyes and an unfilled 
condition of the skin. It is sometimes necessary to determine whether 
starvation resulted from disease or neglect, especially in cases of those 
children which have been reared in foundling homes and hospitals. If 
all food and water be withheld death occurs after forty per cent, of 
the body-weight has disappeared, of which approximately one-half is 
due to disappearance of muscular tissue. Ninety-three per cent, of the 
fat is lost, while the heart and nervous system show the least loss. In 
man death takes place in from seven to twelve days, bodily exercise 
diminishing the length of time. When water is used a person may 
live over forty days. The introduction of many substances, such as 
iron, is necessary for the perfect body. 

Suffocation; Strangulation; Hanging; Drowning. — All 
these produce death by asphyxia, or carbon dioxid poisoning, com- 
bined with oxygen starvation, the signs of which are more or less 
marked. In death from asphyxia there are usually hemorrhages 
into the thymus gland, as well as Tardieu ecchymoses in the pleura 



MEDICOLEGAL SUGGESTIONS 457 

and pericardium. In suffocation there is but little tendency for the 
blood to coagulate, and no marks of violence may be present. The 
dark, fluid blood, possibly hemorrhages from increased blood-pressure, 
general congestion of the lungs, frequently congestion of viscera, often 
blue nails and lips, occasionally suffusion of the face with dark, venous 
blood, and an absence of other pathologic conditions, present a general 
type of morbidity that is not easily mistaken when clearly marked, but 
is difficult to recognize when not conspicuous. 

Strangulation adds the factor of mechanical arrest of respiration, 
and may result from the presence of food, some foreign substance, 
or a growth or swelling in the throat. When due to throttling the 
marks about the neck are of great importance. There may be com- 
pression of veins. 

Hanging may cause death by injury to the spinal cord as well as 
by compression of the blood-vessels and air-passages. The parch- 
ment-like appearance of the skin on the sides of the neck and the 
rupture of the intima of the carotids afford valuable evidence. In 
drowning see if the tongue is protruded between the teeth and whether 
or not punctate hemorrhages are found beneath the pleura. In hang- 
ing, lividity of the face and hyperemia of the conjunctiva occur. 

Wachholz * has shown experimentally that in acute suffocation there 
may be found, along with the soft currant- jelly clots in the heart, solid 
white clots embedded in the meshes of the cardiac muscle. La Cas- 
sagne and Martin have described a method, called docimasie hepatique, 
of diagnosing sudden death by a marked increase in the sugar contents 
of the liver of persons who have died suddenly. Wachholz finds from 
his experiments that no such relation exists. 

Reuter, working with Kolisko, 2 from a study of twenty-two cases 
of throttling and two hundred cases of hanging, thinks that these two 
very similar modes of death may be differentiated from each other. In 
throttling there is (1) cyanosis of the face, with ecchymoses of the 
eyelids and conjunctiva. (2) The scalp, the coverings of the brain, and 
its membranes are always rich in blood. (3) As a rule, hemorrhages 
in the soft tissues of the neck, especially in the muscles, occur. (4) 
There is marked injection of the upper air-passages, combined with 
numerous small hemorrhages. ( 5 ) Injuries to the larynx and hyoid are 



1 Vrtljschr. f. gerichtl. Med., 1902, p. 34. 

2 Zeitschr. f. Heilk., 1901, vol. xxii, p. 145. 



45 g POST-MORTEM EXAMINATIONS 

rare. (6) Rupture of the intima of the carotid is never noted; in only 
three cases were there suffusions into the adventitia. In hanging (i) 
cyanosis of the face is usually not noted ; ecchymoses are seen in twenty 
per cent, of typical and in thirty per cent, of atypical strangulations. 
(2) The amount of blood contained in the organs in the skull varies, 
but usually consists only of that which was present in these parts at the 
time the circulation was interrupted. ( 3 ) Hemorrhages in the muscles 
are rare, — two per cent, in typical and fourteen per cent, in atypical 
cases. (4) Injuries to the laryngeal and hyoid structures are com- 
mon, — sixty per cent, in typical and thirty per cent, in atypical cases. 
(5) Rupture of the intima of the carotids occurs in five per cent, of 
typical and four per cent, of atypical hangings. The external markings 
on the neck are also often different. 

In a case of drowning water or foreign substances may be found 
in the openings of the body, in the respiratory organs, or in the 
stomach, or death may be due to spasmodic arrest of respiration. The 
froth from the air-passages is coarser than that seen in cases of 
oedema. Very soon after death we often find watery fluid in the pleura. 
The spongy condition of the lungs is found only where there has 
been inhalation of water, which does not always happen. After 
decomposition has set in, the evidence of drowning gradually dis- 
appears until it is impossible to make the diagnosis. In drowning the 
bleaching of the palmar and plantar skin surfaces occurs very early. 
Little John x discusses the differences in appearance after drowning 
in salt and in fresh water. Of those drowned in sea water the soft 
parts are rapidly destroyed by crabs and fishes, in some cases the bones 
alone remaining after ten days, while the body undergoes putrefactive 
changes more slowly. He reports a case where calcium phosphate 
crystals studded the pleura. The place in which a person is drowned 
may sometimes be told by the character of the material found in the 
smaller bronchi. Revenstorf 2 determines the freezing-point of the 
blood from both sides of the heart, as more or less of the fluid in which 
an animal is drowned usually passes through the capillaries of the lungs 
and dilutes the venous blood. He concludes that the method, when 
positive, — i.e., when it can be shown that the freezing-point of the 
blood from the right side of the heart is higher than that of the blood 
from the left side, — is valuable as additional evidence of drowning, 

1 Edinburgh Med. Jr., February, 1903, p. 123. 
2 Munch, med. Wchnschr., 1902, no. 45, p. 1880. 



MEDICOLEGAL SUGGESTIONS 459 

and is very easily carried out ; but decomposition rapidly removes any 
difference which may have existed, and the blood is not necessarily 
diluted during death by drowning. 

Cytology. — The different kinds of cells found under various con- 
ditions in the serous cavities form a most inviting field of study. 
Thus, in syphilitic hydrocele we have endothelium; in gonorrhceal 
hydrocele, marked polymorphonuclear leucocytosis ; in tuberculous 
hydrocele, lymphocytosis; in mechanical hydrocele, few or no leuco- 
cytes. Naturally, the age of the process has much to do with the num- 
ber and variety of the cells. 

Semen. 1 — The Florence test should be first applied, a reaction 
common to all semen, and then the material studied microscopically. 
Seminal stains remain intact for years under favorable circumstances 
and give the biologic blood test. 

Schiitze 2 finds in the use of the precipitin method of discovering 
spermatozoa that the animal need not be inoculated with semen or 
testicular cells, but that any albuminous fluid of the animal's semen to 
be proved will produce a serum capable of giving rise to the reaction. 

Toxicology. 3 — The presence of poisons in the animal economy 
may be recognized clinically, chemically, pharmacologically, and 
pathologically. While we have chiefly to do with the latter method, 
the success of the chemist and the pharmacologist depends largely 
upon the procedures adopted for the preservation of material by the 
pathologist at the time of the performance of the autopsy. There 
are certain poisons which may kill without leaving in the tissues any 
specific alterations to be found post mortem, especially when the 
examination is postponed for several days. 

A poison is any substance which, when taken into the system and 
either being absorbed or by its direct chemic action upon the parts 
with which it is in contact, or when applied externally and entering the 
circulation, is capable of producing deleterious results. (Wormley. ) 4 
Poisoning commonly results from alcohol, morphine, lead, arsenic, 
phosphorus, oxalic acid, carbolic acid, etc. ; from food (bromatotoxis- 

1 See Simon's Clinical Diagnosis, 1904, p. 664, or any other recent work for the 
method of applying this test; Arch, d'anthrop. crimin., vols, x and xi. 

2 Zeitsch. f. Hyg. u. Infectionskrank., 1901, vol. xxxvi, p. 5. 

3 Much of the material in this section is taken from Kobert's Lehrbuch der 
Intoxikationen, Stuttgart, 1902, and Glaister's Medical Jurisprudence, 1903. 

4 To show the difficulty of any definition, carbolic acid when sufficiently 
diluted may serve as a food. Ziegler, Gen. Path., xi, p. 23. 



4 6o POST-MORTEM EXAMINATIONS 

mus) ; from meat (kreotoxismus) ; from milk products ( galactotoxis- 
mus) ; from fish and shell-fish (ichthyotoxismus, mytilotoxismus) ; 
and from grain 1 (sitotoxismus) ; of the latter poisoning there are three 
kinds, — ergotism, lathyrism, and pellagra. 

It should always be remembered that conditions which we are 
apt to regard as being alone produced by strictly pathologic processes 
are often due to poisons. Thus, toxic inanition may be produced by 
chronic poisoning with mercury, lead, arsenic, etc. ; fatty degenera- 
tion, by phosphorus, alcohol, Amanita phalloides, 2 etc. ; calcification 
of the renal epithelium, by corrosive sublimate ; and amyloid degenera- 
tion, by repeated injections of turpentine. 

Suspicious undissolved foreign bodies may be found in the vomit 
and in the contents of the alimentary tract, as arsenic (white, metallic, 
and various salts), antimony, sulphid of antimony, mercury and its 
preparations, as calomel, oxid, and bichlorid, chrome salts, oxalates, 
cantharides, nux vomica beans, heads of matches, and parts of poison- 
ous plants. In one of my cases diagnosed as a heat-stroke, with a 
temperature of over no° F., the finding of leaves of Datura stra- 
monium in the stomach led to the correct diagnosis. Morphine even 
when given hypodermically may be found in the stomach contents. 
Certain diseases and chemicals, mentioned on pages 31 and 32, may 
be detected by odors coming from the body or from the various 
cavities when opened. 

When the acidity or alkalinity of the gastric contents is abnor- 
mally increased, certain reagents are to be suspected, such as acids, 
alkalies, and potassium cyanid. The liver especially shows poisoning 
by phosphorus, antimony, arsenic, and toxins, while the kidney is 
affected by hemolytic and methsemoglobinic poisons, by oxalic acid, 
oxamid, mercury, silver salts, preparations of cantharides, etc. The 
spectroscopic picture of the blood should always be obtained as soon 
after death or removal from the body as possible. The addition of 
a little distilled water is admissible in methemoglobinemia, but even 
here it is better at once to seal hermetically in glass tubes with exclu- 
sion of air as far as practicable. If the blood coming from veins is 
fluid and scarlet, suspect carbon monoxid poisoning; if a laky purple 

1 Recent Japanese writers consider that kakke (beriberi) is due to the con- 
tinued use of spoiled dry rice. 

2 W. W. Ford, of Baltimore, thinks that he is able to produce an antitoxin 
for poisonous mushroom intoxication. Med. News, October 21, 1903. 



MEDICOLEGAL SUGGESTIONS 



461 



fluid, not changing on the exposure to oxygen, suspect cyanid. If 
the muscles of the abdominal walls are drawn and contracted spirally, 
we may suspect any of the instant poisons, as strychnine or potassium 
cyanid. I have for a long time had a bottle of blood from, a case of 
cyanid poisoning, and have many times exposed it to the air by re- 
moving the cork, yet it is apparently still in a good state of preser- 
vation and smells of hydrocyanic acid. 

The left heart is found markedly contracted in death from over- 
doses of members of the digitalis group, veratrine, and barium salts. 
As already stated, the odor of the poison may sometimes be detected 
on exposing the brain. Much attention has been paid to the actions 
of poisons on the central nervous system, and the rapid diagnosis of 
hydrophobia by this method should not be forgotten. For a descrip- 
tion of the Negri bodies in hydrophobia, see the Zeitschrift f. Hyg. u. 
Infectionskrank., 1903, vol. xliv, p. 519. The joints are alleged to be 
inflamed after poisoning by colchicum. Testicular atrophy is said 
to be induced by the long-continued use of capsicum, solanus pseudo- 
capsicum, and conium maculatum. 

The mucous membrane of the stomach is irritated and stained by 
many poisons, as sulphuric acid (black), nitric acid (yellow), oxalic 
acid (white), bromin (red), iodin (purple), and by a large number 
of metallic salts, as sulphid of arsenic (yellow), chromate of potas- 
sium (red), etc. I have, however, seen several cases of arsenical 
poisoning with but little inflammation of the gastric mucosa. 

Among the questions to be answered in every case of suspected 
poisoning are: Was death caused by a poison originating within or 
without the body? What poison caused death? Is the substance 
found by the chemist the poison which killed the person in whose body 
it was found? Might not the poison have been administered as a 
medicine? Is the poison present in such quantity as always causes 
death? Were there attendant circumstances which conduced to the 
fatal result? Was more than one poison given? How and when 
was the toxic substance administered? Could poison have been given 
and yet not be discovered? Was the fatal dose taken for purposes of 
suicide? Was it administered with the object of killing? Was it ad- 
ministered accidentally? Did the person for whom it was intended 
receive the poison? Could the toxic symptoms be simulated? Was 
cremation practised in order to destroy evidences of poisoning? Was 
there any motive for homicide? Are there any accomplices? What 



4 6 2 POST-MORTEM EXAMINATIONS 

became of the vehicle in which the poison was administered? Was 
there any poison found ? Was any poison destroyed ? 

In order to convict of murder in the first degree in case of poison- 
ing, it is the manifest duty of the District Attorney to prove three 
things to the Court and Jury beyond any reasonable doubt : first, that 
the person alleged to be murdered is dead, a fact proved by the identi- 
fication of the cadaver; second, that death was caused by the poison 
under consideration and did not take place by natural causes ; and third, 
that the party or parties on trial administered the drug with felonious 
intent, and that it was not taken accidentally or with suicidal purpose. 
Naturally, the province of the medical expert will deal largely with the 
second condition. 

On request of ex-Judge Stevenson, the counsel for the defence, 
in the case of the Commonwealth of Pennsylvania vs. John and Emma 
Williams, Judge McMichael issued the following order, under which 
I made a post-mortem examination of the bodies of the three children, 
after the experts for the Commonwealth had already made an original 
examination and two disinterments. 

" And now, to wit, this sixteenth day of February, A. D. 1903, it is ordered and 
directed that the defendants through their experts shall have access to the bottles and 
prescriptions taken from 1135 Vienna Street, and also that they shall be permitted to 
exhume the bodies of Anna, Josephine, and Laura Williams, and to make such ex- 
amination as they shall deem necessary and proper, and to remove such portions of 
said bodies as may be necessary to a proper and adequate chemical examination and 
analysis to determine the causes of death. It being understood, however, that the 
Commonwealth shall during these investigations be represented by an expert that 
they may select." 

Nearly every toxicologist has his own classification of poisons. 
Thus, one divides them into mineral, vegetable, animal, and mechanical 
groups ; another into irritants, narcotics, and narcotic irritants ; a third 
into chemic and vital poisons ; a fourth into those which produce local 
irritations, act upon the blood, and upon the nervous system and heart, 
etc. All such divisions are arbitrary, as quickly becomes evident on 
attempting to place the various poisons in their proper subclasses. 

SCHEME FOR THE DIVISION OF POISONS. 



Inorganic 



Irrespirable gases : carbon monoxid, coal gas, chlorin, bromin, 

hydrofluoric acid, sulphur dioxid, etc. 
Chemic : sodium hydrate, sulphuric acid, etc. 
Irritant : arsenic, antimony, mercury, phosphorus, etc. 



MEDICOLEGAL SUGGESTIONS 



463 



Irritant 



SCHEME FOR THE DIVISION OF POISONS.— ( Continued. ) 

[ Irrespirable gases : chloroform, ether, formalin, etc. 
Chemic : carbolic acid, acetic acid, pyrogallic acid, etc. 

Vegetable : gamboge, colchicum, squill, etc. 
Animal : cantharides, etc. 

Narcotic : opium, hyoscyamus, belladonna, can- 
nabis indica, etc. 
Organic \ Alkaloidal \ Sedative : digitalis, hydrocyanic acid, aconite, 

conium, etc. 
Excitomotor : strychnine, ergot, etc. 
Antiseptics : creolin, lysol, etc. 
Synthetical \ Antipyretics : antipyrin, acetanilid, etc. 
Hypnotics : sulphonal, trional. 
Bacterial : toxins, hemolysins, cytolysins. 
,) Animal : snakes, scorpions, ptomaines, etc. 
Vegetable : ricine, abrine, etc. 



I To: 



SYMPTOMS OBSERVED AFTER THE ADMINISTRATION OF THE 
MORE COMMON POISONS. 1 



Acute Symptoms : 

1. Death within a few seconds or min- 

utes. 

2. Deep coma. 



Think of: 

Hydrocyanic acid ; potassium cyanid ; 
carbonic acid; carbolic acid. 

Alcohol; morphine; opium; chloral 
hydrate and its derivatives; sulpho- 
nal; chloroform and its derivatives; 
carbon monoxid ; anilin oil ; oxybu- 
tyric acid. 

Corrosive acids; corrosive alkalies; 
nicotine; arsenic; antimony; col- 
chicine. 

Phosphorus ; cocaine ; under certain 
circumstances any of the powerful 
convulsive remedies; enzymes. 
5. Mania ; furious delirium ; psychic Chronic alcoholism ; atropine ; canna- 



3. Collapse. 



4. Feverish rise of temperature. 



excitement. 

6. Mental disturbances of the most di- 
verse kind. 



7. Violent ; at times, tetanic convul- 
sions. 



binone ; camphor ; physostigmine ; 
veratrine; lead (in animals). 

Alcoholism ; morphinism ; cocainism ; 
pellagra; ergotism; inhalation of 
ether ; saturnism ; mercurialism ; 
poisoning by bromid ; iodoform ; car- 
bon bisulphid. 

Strychnine ; toxin of tetanus ; salts of 
ammonia ; cytisine ; cornutine ; pic- 
rotoxin ; cicutoxin ; active principles 
of digitalis ; cocaine ; santonin ; aconi- 
tine ; gelsemine ; filicic acid. 



1 This table and the following one are from Robert's Compendium der Toxi- 
kologie, 1903. 



464 



POST-MORTEM EXAMINATIONS 



SYMPTOMS OBSERVED 
Acute Symptoms: 

8. General paralysis, for the most part 

ascending. 

9. Paralysis of individual groups of 

muscles. 
10. Dilatation of the pupil. 



IN CASES OF POISONING. 
Think of: 
Coniine ; curarine ; colchicine. 

Lead; arsenic; carbon bisulphid. 



n. Contraction of the pupil. 



12. Amaurosis. 



13. Diplopia and ptosis. 

14. Conjunctivitis. 



Atropine ; hyoscyamine ; scopolamine ; 
cocaine; ephedrine; aconitine; coni- 
ine; gelsemine; sausage poisoning. 
Muscarine; pilocarpine; nicotine; are- 
caline ; morphine ; codeine ; opium ; 
physostigmine. 
Quinine ; salicylic preparations ; extract 
of male fern; belladonna; ursemic 
poisoning. 
Sausage and fish poisoning. 
Irritating vapors (sulphurous, hydro- 
chloric, nitric, and osmic acid ; ni- 
trogen dioxid ; hydrofluoric acid ; 
chlorin ; bromin ; carbonyl chlorid ; 
ammonia ; ethereal oil of mustard ; 
croton oil vapor) ; irritating kinds of 
dusts, as root of ipecacuanha, quil- 
laja bark, pepper, chromate, picrate; 
arsenism ; phenylendiamin, chrysaro- 
bin, [formalin]. 
Opium ; morphine ; aconitine ; musca- 
rine ; pilocarpine ; nicotine ; physo- 
stigmine ; lobeline ; antimony. 
Atropine, as well as belladonna, stra- 
monium, and hyoscyamus ; hyoscya- 
mine; scopolamine; sausage and fish 
poisoning. 
17. Urticaria or scarlatiniform erythema. Atropine ; hyoscyamine ; antipyrin ; quin- 
ine ; balsam of copaiba ; cubebene ; 
chloral hydrate; iodin; morphine; 
and many internal remedies ; hand- 
ling of nettles (urtica). 
Croton oil ; curcas oil ; cardol ; rhus 
toxicodendron ; powdered cinchona 
bark ; carbolic acid ; tar. 
Anilin colors; aurantia; chrysoidin; 
malachite green; Bismarck brown; 
annotto ; anilin yellow. 
Bromid; arsenical and antimonial prep- 
arations; powdered ipecacuanha. 
Spanish fly; ranunculus acris; ranun- 
culus sceleratus, etc. 
Argyria ; mercurialism ; saturnism ; ar- 
senical melanosis ; bronzed diabetes. 



15. Moist skin. 



16. Skin conspicuously dry, even in a 
warmed bed. Mouth and throat 
parched. 



18. Eczematous eruptions of the skin. 



19. Diffuse dermatitis, with perspiration 
of the hands. 



20. Acne pustules. 

21. Blisters containing clear serum on the 

skin, or even in the mouth. 

22. Dark, dirty discoloration of the skin, 

which is not, however, cyanotic. 



MEDICOLEGAL SUGGESTIONS 
SYMPTOMS OBSERVED IN CASES OF POISONING. 



465 



Acute Symptoms : 

23. Bluish discoloration of the peripheral 

portions of the body [like those 
seen in Raynaud's disease]. 

24. Cyanosis. 

25. Yellowish-brown discoloration of the 

conjunctiva, alone or in combina- 
tion with that of the skin. 



26. Discoloration primarily of the tongue 
and the mucous membrane of the 
mouth. 



27. Secondary discoloration of the gums. 



28. Specific odor to the breath. 

29. Coryza. 

30. Salivation. 



31. Metallic cough and aphonia. 

32. CEdema of the glottis. 

33. (Edema of the lungs. 



34. Luminosity of the breath and vom- 

itus. 

35. Increased liver dulness. 

36. Diarrhoea with vomiting. 



Think of: 

Gangrenous ergotism ; carbolism ; phos- 
phorism. 

Nitrobenzol; benzokoll ; anilin; tolui- 
din ; acetanilid ; exalgin. 

Phosphorus; helvellic acid; potassium 
chlorate ; nitroglycerin ; sodium ni- 
trite ; amyl nitrite ; pyrogallol ; arsen- 
iuretted hydrogen ; ictrogen [lupin- 
otoxin], in animals. (In picric acid 
and picrates the discoloration is a pure 
yellow.) 

Reddish yellow — chromic acid and the 
bichromates. Yellow — nitric and pic- 
ric acid. Brown — iodin; bromin. 
Greenish-blue — salts of copper ; 
Schweinfurth green. Whitish — cor- 
rosive alkalies ; corrosive acids ; cor- 
rosive metallic salts ; carbolic acid. 

Lead ; silver ; mercury ; bismuth. 
[Augment, for diagnostic purposes, 
by the direct application of sulphur- 
etted hydrogen gas to the gums.] 

(See pages 31 and 32.) 

Iodin ; bromin. 

Pilocarpine ; muscarine ; arecaline ; 
nicotine ; cornutine ; physostigmine ; 
cytisine; mercury; ammonia; sapo- 
nine [a glucoside contained in Sapo- 
naria officinalis'] ; cantharidin ; caus- 
tics. 

Atropine ; hyoscyamine ; scopolamine ; 
sausage poisoning. 

All caustic poisons. 

Morphine ; muscarine ; pilocarpine ; 
ammonia ; nitric acid vapors, etc. ; in- 
halation during the swallowing of sub- 
limate and other corrosive poisons. 

Phosphorus. 

Phosphorus ; agaricus bulbosus ; poley 

oil ; alcohol. 
Salts of antimony; arsenic; digitalin; 

pilocarpine ; nicotine ; muscarine ; 

colchicine; corrosive poisons; salts 

of copper ; zinc salts ; colocynthine ; 

emetine; cephaeline; croton oil, etc. 



4 66 POST-MORTEM EXAMINATIONS 

SYMPTOMS OBSERVED IN CASES OF POISONING. 



Acute Symptoms : 

2,7. Vomiting without diarrhoea. 

38. Colic with constipation. 

39. Colic with diarrhoea. 

40. Diarrhoea without vomiting. 

41. Pulse continuously and markedly 

slowed. 

42. Pulse paroxysmally and markedly 

slowed and thread-like. 

43. Pulse first slowed, then irregular, 

finally accelerated. 



44. Pulse greatly accelerated. 

45. Abortion. 

46. 6-12-hour period of good health be- 

tween the poisoning and the ap- 
pearance of the symptoms. 



Think of: 

Apomorphine ; lobeline ; cytisine. 

Lead salts. 

Barium salts. 

Jalap; podophyllotoxin ; croton oil; 
calomel, etc. 

Opium; morphine; muscarine; areca- 
line ; physostigmine ; baryta ; all nar- 
cotics. 

Lead salts, but only during an attack of 
lead colic. 

Digitalis ; hellebore ; adonis ; coronilla ; 
cheiranthus ; nerium ; scilla ; stro- 
phantus ; convallaria ; pilocarpine ; 
nicotine ; scopolamine. 

Belladonna ; hyoscyamus ; atropine. 

Sabina; thuja; rue; mentha pule- 
gium ; phosphorus ; ergot ; lead. 

Most of the poisonous fungi, but espe- 
cially Amanita phalloides; also com- 
bined arsenic. 



TABLE OF THE MOST STRIKING CHANGES WHICH TAKE PLACE 
IN THE URINE AFTER THE ADMINISTRATION OF THE MORE 
COMMON POISONS AND MEDICINES. 



Urinary Condition : 

1. Very acid reaction. 

2. Reaction strongly alkaline. 



3. Odor like violets. 

4. Odor like garlic. 

5. Odor of methylmercaptan. 

6. Odor of rotten eggs. 

7. Odor of ammonia. 

8. Achromatic crystals, with acid urine. 

9. Leucocytes and epithelial casts. 
10. Yellow to yellowish-red color. 



Think of: 

Mineral acids ; acid salts of the metals. 

Corrosive alkalies ; alkaline carbonates ; 
salts of organic acids, with the excep- 
tion of oxalic acid. 

Oil of turpentine and related ethereal 
oils when employed medicinally. 

Preparations of tellurium when em- 
ployed medicinally. 

Asparagus, sometimes used medici- 
nally in the form of a syrup. 

Cystinuria exists, or the thiosulphate of 
sodium has been taken medicinally in 
large doses. 

Ammonisemia ; cystitis caused by strong 
bases [and certain bacteria]. 

Oxalic acid ; binoxalate of potassium ; 
oxamid ; parabanic acid. 

Cantharidin ; potassium cantharidate ; 
virus of scarlet fever. 

Picric acid; picrates. 



MEDICOLEGAL SUGGESTIONS 
EFFECT OF POISONS UPON THE URINE. 



467 



Urinary Condition 

11. Urine icteric brown. 

12. Urine, reddish. 



13. Urine colored wine-red by hsemato- 

porphyrin. 

14. Urine becomes scarlet upon putre- 

faction. 

15. Urine contains albumin and red 

blood-corpuscles. 

16. Urine contains blood pigment in 

solution. 



17. Urine contains methaemoglobin. 



18. Urine contains urobilin. 

19. Urine becomes black-green on expo- 

sure to the air. 

20. Urine is green when voided. 

21. Urine on exposure to the air becomes 

blackish brown or even pure black. 



22. Urine reduces Fehling's solution and 
gives off carbon dioxid with yeast. 



23. Urine reduces Fehling's solution, but 
yields with yeast little or no carbon 
dioxid. 



24. Urine polarizes light to the right. 



25. Urine polarizes light to the left. 

26. Urine contains increased number of 

paired sulphuric acids and dimin- 
ished number of sulphates. 



Think of: 

Phosphorus, toluylendiamin ; cephalan- 

thine ; ictrogen. 
Senna leaves ; rhubarb root ; campe- 

cia wood (logwood); hematoxylin; 

fuchsin; pyramidon, 1 antipyrin. 
Sulphonal ; trional ; tetronal ; lead 

(rarely). 
Santonin ; santonica seeds ; chenopo- 

dium. 
All corrosive poisons. 

Arseniuretted hydrogen ; helvella escu- 
lenta (helvellac acid); cyclamin ; 
solanine ; and other saponiferous sub- 
stances. 

Potassium chlorate ; sodium nitrite ; 
amyl nitrite; pyrogallol ; chrysaro- 
bin ; kairin ; quinine. 

Lead. 

Carbolic acid ; cresol ; lysol ; creosote ; 
guaiacol. 

Methylen blue. 

Melanuria, associated with melanotic 
tumors and with hemochromatosis. 
It may be produced artificially by in- 
jections of melanin. 

Phloridzin ; salts of uranium ; curarine ; 
hydrocyanic acid ; atropine ; amyl ni- 
trite ; chromates and bichromates ; 
bichlorid of mercury; cantharidin. 

Chloral hydrate ; menthol ; thymol ; 
many of the ethereal oils ; carbon 
monoxid ; chloroform ; formic acid 
and formates ; free oxalic acid ; ben- 
zaldehyd ; morphine. 

Phloridzin ; salts of uranium ; curar- 
ine ; hydrocyanic acid ; atropine ; 
amyl nitrite ; chromates and bichro- 
mates ; bichlorid of mercury ; can- 
tharidin. 

Chloral hydrate ; menthol ; thymol ; 
many of the ethereal oils. 

Carbolic acid; cresol; lysol; creosote; 
guaiacol ; kairin ; antifebrin ; anilin ; 
paramidophenol. 



x The red color of urine from pyramidon is due to rubazonic acid, which is 
soluble in chloroform. 



4 68 POST-MORTEM EXAMINATIONS 

EFFECT OF POISONS UPON THE URINE. 

Urinary Condition: Think of: 

27. Urine contains leucin and tyrosin. Phosphorus ; acute yellow atrophy of 

liver ; pellagra. 

28. Few drops of the urine will dilate Atropine; hyoscyamine; scopolamine; 

pupils of a cat's eye. cocaine; tropacocaine. 

29. Few drops of the urine given to a Strychnine ; nux vomica. 

frog cause tetanic convulsions. 

30. Few drops of the urine upon a cult- All combinations of arsenic, with the 

ure of Penicillium brevicaule give single exception of triphenylarsin. 

off an odor of garlic. Selenium and tellurium compounds 

give a similar reaction, but different 

odors. 

31. There is sometimes anuria present. Oxalic acid; binoxalate of potassium; 

oxamid ; cantharidin ; bichlorid of 
mergury. 

32. The urine is voided with strangury. Pilocarpine ; anilin dyes ; canthari- 

din. 

33. The urine is voided with difficulty on Cantharidin ; potassium cantharidate ; 

account of priapism. Gyrinus natator. 

Acids. — Poisoning may be produced by mineral and vegetable 
acids, the corrosive action depending largely upon the strength and 
properties of the acid at the time of its introduction into the body. 
Naturally those parts are most affected which remain longest in con- 
tact with the acid. The mucous membrane of the lips rarely escapes, 
and often the skin of the lower lip is discolored. The mucous mem- 
branes of the mouth, oesophagus, and stomach are acted upon, and 
oedema of the glottis is common. The tissues are softened ; sometimes 
there is actual destruction followed by necrosis, which may lead to per- 
foration. Around these areas of corrosion is a more or less marked 
hemorrhagic inflammation. If the acid was diluted, this inflammation 
is more marked and the corrosion less so. The blood in the external 
veins of the stomach is usually black. Acids neutralize to a large 
extent the alkalinity of the blood and thus produce disturbance in 
breathing and in the circulation. In all cases where death does not 
occur quickly, changes are seen in the parenchymatous organs, espe- 
cially the kidneys. The color produced by different acids is somewhat 
characteristic. In carbolic acid poisoning the oesophagus is of a silver- 
gray color, the stomach is thrown into rugae, and the mucosa is of a 
rough, brownish, cracked appearance. The urine may be dark in color 
and smell strongly of phenol. Gangrene of fingers may occur from 
the use of carbolic acid. In poisoning by sulphuric acid the mucous 



MEDICOLEGAL SUGGESTIONS 469 

membrane of the upper intestinal tract is brownish or even black, due 
to the extraction of water from the tissues and the action of this acid 
on the coloring matter of the blood. It is often difficult or impossible 
to say whether perforation occurred during life or after death. While 
putrefaction may occur in the stomach, other parts of the body may be 
preserved. The effects of hydrochloric acid are similar to those of 
sulphuric acid, but less marked, corrosive action on the skin being 
almost absent. The eschars are white, and the false membrane sloughs 
off, if life persists for some time. If death is delayed for twenty-four 
hours, there is fatty degeneration of the kidneys. The blood may be 
fluid or thickened. Nitric acid imparts to the skin and mucosa a yel- 
lowish tinge, owing to the formation of a xanthoprotein of picric acid. 
The stomach may be perforated. In oxalic acid and oxalate of potas- 
sium poisoning white to grayish corrosion of the upper intestinal tract 
occurs, crystals of oxalates of lime being found in the blood and 
kidneys. Concentrated acetic acid may also cause death. 

Aconite. — In aconite poisoning the physiologic test should always 
be applied. No characteristic lesions are found post mortem. 

Alcoholism. — There are no really characteristic lesions. I. Gastro- 
intestinal Tract. — (1) Chronic hypertrophic gastritis may be followed 
by (2) atrophic gastritis with dilatation. (3) Hypertrophic oar 
atrophic cirrhosis of the liver. Orth says, " Most drinkers have no 
cirrhosis of the liver, but a fat liver, and many with liver cirrhosis are 
not drinkers of alcohol." II. Vascular System. — ( 1 ) The heart is usu- 
ally enlarged and its muscle often thin, fatty, and friable. (2) The 
blood-vessels are frequently sclerosed, especially those arteries exposed 
to much strain. (3) The venules of the cheek and nose are often dis- 
tended. III. Central and Peripheral Nervous System. — (1) The pia- 
arachnoid is thickened, with wasting of its convolutions. (2) The blood- 
vessels are thickened, tortuous, and may show miliary aneurisms. (3) 
The motor nerves of the muscles are sometimes altered (multiple neu- 
ritis). IV. Genito -urinary Tract. — (1) The kidneys are enlarged, 
cyanotic, and indurated. (2) The bladder is thickened and often shows 
signs of chronic cystitis. V. Ductless Glands. — Quervain 1 points out 
the destructive influence of alcohol on the thyroid gland, and accounts 
thereby for the spontaneous myxcedema sometimes seen in the children 
of alcoholics. 

1 La semaine med., 1905, vol. xxv, no. 44. 



47o 



POST-MORTEM EXAMINATIONS 



Alkalies and Caustic Salts. — Alkalies — potash, soda, and 
ammonia — act much the same as acids except that the involved areas 
are brown or black, due to changes in the blood, and are less brittle. 
The epithelium is shed in threads and there are ecchymotic folds of the 
mucosa. Capillary bronchitis is common, as the inhalation of am- 
monia causes intense congestion of the respiratory mucous membrane. 
Stricture of the oesophagus often results in patients who recover. In 
one of my cases cancer followed at the seat of stricture due to the 
accidental drinking of lye. 

Antimony. — Poisoning is usually due to tartar emetic. The mu- 
cous membrane from the mouth to the duodenum inclusive is usually 
inflamed, and often ulcerated and covered with stringy mucus. In 
chronic cases there is considerable emaciation ; chemic tests will deter- 
mine its true character. Klosowski employed antimony to murder 
three women ; on exhumation their bodies were found to be preserved 
to a marked extent. 

Arsenical Poisoning. — This may be: (a) Acute, (b) Subacute. 
(c) Chronic. In acute arsenical poisoning there is generally a marked 
gastro-enteritis, which differs in severity according to the amount taken. 
The mucous membranes are intensely swollen, cedematous, and present 
small, emphysematous bullae or diphtheritic exudation. Petechial erup- 
tions may occur in both the stomach and intestines. The contents of the 
stomach are usually of a brownish color. In subacute arsenical poison- 
ing or where large doses have been taken, patches varying in size from 
a dime to a silver dollar, consisting of an opaque, white, yellowish, or 
even violet coagulated lymph mixed with arsenous acid and firmly fixed 
to the mucous membrane, with signs of intense inflammation around 
them, may be found in the bowels. White spots of arsenic are some- 
times discovered between the rugae, and fatty degeneration of the intes- 
tinal epithelium and of the viscera is also present. Chronic arsenical 
poisoning is characterized by wide-spread fatty degeneration, affecting 
especially the heart, liver, spleen, and kidneys. Marked changes are 
also found in the voluntary muscles, which show wasting-, fatty degen- 
eration, and often cirrhosis. Trophic changes are common, such as 
overgrowth of hair and nails, both of which are harsh and brittle. In 
life the skin is harsh, dry, and frequently shows eruptions. Although 
arsenic is rapidly eliminated from the body, enough usually remains for 
purposes of identification. The urine should always be saved. The 
white material should be examined microscopically for the octahedral 



MEDICOLEGAL SUGGESTIONS ^y I 

crystals, and in England for soot and indigo, as the law there requires 
the retailing pharmacist to mix his arsenic previous to selling with 
one or the other of these substances. The cyanid of cacodyl, dis- 
covered by Cadet, appears to be one of the most poisonous compounds 
known. There are no characteristic lesions post mortem. It is a 
disputed question as to whether bodies keep a longer time after death 
in arsenical cases. The manifold ways in which arsenic may acciden- 
tally get into the system and thus cause death should always be remem- 
bered. From wall-paper it enters the system as dust and diethylarsin, 
due to the action of various moulds, such as the Penicillium brevicaule. 
These organisms may, in turn, be used as the means of detecting arsenic 
by the odor evolved from the presence of minute traces. In England 
there were recently thousands of cases of arsenical poisoning, with 
many deaths, due to the drinking of beer made from glucose contain- 
ing arsenic. The X-rays have been used to determine the presence of 
the crystals in an unopened stomach. Such a picture with the photo- 
micrographs of portions used in making tests forms valuable evi- 
dence when produced in court during the giving of testimony. Gautier, 
a celebrated French chemist, claims, contrary to general belief, that 
arsenic is a normal weighable constituent of the thyroid gland. He also 
declares 1 that one cubic kilometre of sea water contains three thousand 
kilogrammes of arsenic. The arsenic localizes especially in the ecto- 
dermic tissues and in the cells in the nature of nuclein and ferments. 
Rough-on-rats, which contains barium, and Paris green are favorite 
preparations with would-be suicides. In 1905 a number of valuable 
animals belonging to the New York Zoological Garden died from 
the effects of arsenical poisoning due to the eating of flies, an 
arsenical water having been freely used for the purpose of killing off 
these pests. 

Atropine. — Fatal cases of atropine poisoning, either suicidal or 
homicidal, are rare, though accidental poisoning by the Datura stra- 
monium is common. Death is caused by asphyxiation, the symptoms 
resembling those seen in heat-exhaustion. Careful search should be 
made in the stomach for any seeds, leaves, or berries. 

Boric Acid. — A crusade is now going on in the United States 
against the use of boric acid as a preservative for foodstuffs. In one 
of the cases tried in Philadelphia seven and a half grains of boric acid 

1 Bull, de la soc. de chem. de Paris, January 5, 1903. 



472 



POST-MORTEM EXAMINATIONS 



were found in a quart of milk. Wiley has made some feeding experi- 
ments on a large scale and finds that the above amount cannot be taken 
for fifty days without the production in some cases of unfavorable 
results. Best * reports a fatal case of boric acid poisoning, and adds 
histories of three other cases from the literature on this subject. 

Chloral Hydrate. — Urine should always be reserved for 
chemic examination. Chloral is often taken with other drugs, as 
morphine, and after a debauch; this renders it difficult or even im- 
possible to tell just what effect the chloral actually has had on the 
system. This is the drug which is so often used as " knock-out drops." 

Chloroform and Ether Poisoning. — The saying of Tait, that 
the Coroner has to do with chloroform death, while the physician signs 
the death certificate in ether cases, is well known. Fright may have 
something to do with death in these cases. Signs of asphyxia are usu- 
ally present and the characteristic odor is capable of determination. But 
although the anaesthetic may have been given, yet death may be due 
to other causes. It is much disputed how chloroform kills. If the 
heart be already weakened by fatty degeneration, it would seem as 
if death were due to a direct action upon this weakened organ. Other- 
wise it is due to paralysis of the central nervous system and direct 
action upon respiration. Idiosyncrasy would also seem to play an 
important part. Experimentally repeated inhalations of chloroform 
in dogs may produce hepatic cirrhosis. 2 

Cocaine Poisoning. — At postmortem the heart is found in diastole 
and the nerve-centres are said to be congested. Cocaine should be 
tested for before making the diagnosis. 

Copper. — The lining walls of the stomach often have a bluish or 
greenish tinge. On the application of ammonia the coloration deepens 
into a darker shade of blue, or the green is converted into this color. 
Part of the toxic effect of the arsenite of copper is due to the copper. 
There is marked gastro-enteritis, with ulceration, necrosis of the mu- 
cosa, and at times perforation. Brouardel 3 has written an interesting 
account of this form of poisoning, which was used formerly more 
frequently than it is now. Copper sulphate, when added to reservoirs 
in the proportion of i to 100,000, will rid the water of algae. The 



1 Jr. Amer. Med. Assoc, September 17, 1904, p. 805. 

2 Herter and Williams, Science, November 17, 1905. 



3 La med. mod., September 17, 1902, p. 305. 



MEDICOLEGAL SUGGESTIONS 473 

attempt to purify drinking water by adding 1 part to 1,000,000 of water 
must be considered a dangerous experiment, though cupric sulphate 
will kill typhoid bacilli in laboratory experiments when used in this 
strength. Zinc, tin, and barium salts may also cause death in an 
overdose. 

Ergot Poisoning. — After death from ergot poisoning the arteries 
are found contracted and the abdominal viscera inflamed. In the 
chronic form the posterior columns of the cord are sclerosed and micro- 
scopic sections resemble those characteristic of locomotor ataxia. When 
given to chickens in sufficient quantities gangrene of the comb is 
produced. 

Formaldehyd. — Bock 1 reports a case of poisoning by formalin in 
an imbecile twenty-six years of age. From one to three ounces of a 
four per cent, solution were taken. Death occurred thirty-two hours 
later. The stomach was necrotic, dark, tough, and leathery. 
Kliiber, 2 Zorri, 3 and Levison 4 have also reported cases of poisoning by 
formalin. Formic acid will be found in the urine, the secretion of 
which may almost cease. 

Hydrocyanic Acid and Cyanid of Potassium Poisoning. — The 
mucous membrane of the stomach is markedly and uniformly injected 
and congested. The odor of bitter almonds is detected at once on open- 
ing the abdomen. It should always be remembered that, if the post- 
mortem is not made for thirty-six hours after death, all the hydrocyanic 
acid may be converted into formic acid. The blood is dark and fluid 
and keeps for a long time without undergoing decomposition. There 
is formed a direct combination with the haemoglobin ( cyanmethaemo- 
globin), and death, when it ensues, comes on quickly, at times within 
several minutes; if the patient lives over an hour, recovery may be 
expected. Paralysis of the respiratory and circulatory systems occurs. 
(Ziegler.) 

Illuminating Gas and Carbon Monoxid Poisoning. — These 
two poisons are not quite alike in their action, though the poisonous 
properties of illuminating gas are largely due to the considerable 
amount of carbon monoxid which it contains, especially if of the 
variety known as " water gas." The body may appear quite life-like, 

1 Fort Wayne Medical Journal Magazine, July, 1899, p. 249. 

2 Munch, med. Wchnschr., October 9, 1900, p. 1416. 
8 Ibid., November 13, 1900, p. 1588. 

4 Jr. Amer. Med. Assoc, June 4, 1904, p. 1492. 



4 ^ 4 POST-MORTEM EXAMINATIONS 

with even a rosy hue upon the cheeks. After death the blood retains 
its bright cherry color for some time, especially in the brain, and when 
shaken forms a violet froth. All color reactions should be studied at 
once, before giving time for the oxygen of the air to act upon the blood. 
The skin and internal organs, as also the patches of post-mortem 
congestion, are bright red. The lungs are frequently congested, and 
afford a favorable place to detect the odor of illuminating gas. Carbon- 
monoxid haemoglobin produces two absorption bands near D and E 
like oxyhemoglobin, the latter, however, being reduced by the addi- 
tion of the sulphid of ammonium. The blood should not be taken 
from the heart for this purpose, but from the smaller vessels in the 
muscles. It is well to remember that the spectroscopic test may even 
be secured several months after death in favorable circumstances. 
To detect a small quantity of carbon monoxid in the air of a room 
fresh normal blood is added to distilled water until the latter is faintly 
tinged ; about five cubic centimetres are placed in a flask of some one 
hundred and fifty cubic centimetres' capacity and agitated several 
minutes in the suspected atmosphere ; if the noxious gas be present, the 
liquid assumes a rose tint and gives the characteristic spectrum. Air 
is poisonous when it contains 0.02 per cent, of the gas. ( Gruber. ) In 
cases which live a day or so and then die bilateral softening may occur 
in the region of the inner capsule and the caudate and lenticular nuclei. 
The victim may die from a dose of some other poison taken with suicidal 
intent before turning on the gas. 

Iodin Poisoning. — In iodin poisoning the iodin is eliminated by 
the lungs as well as by the urine. 

Lead Poisoning. — In acute lead poisoning there is marked gastro- 
enteritis, and the bowels usually contain a large amount of blackish 
fluid. The kidneys show evidence of acute diffuse nephritis. In chronic 
lead poisoning the distinctive features are a marked fatty degeneration 
affecting the muscles, kidneys, spleen, and liver. There is often marked 
cirrhosis with atrophy of these organs. Arteriosclerosis with hyper- 
trophy of the heart is also marked. Distinct gouty deposits are often 
found, particularly about the big toe. The brain is sometimes shrunken 
and dry, the blood-vessels being constricted; or these organs may be 
pale and extremely firm, or pale and cedematous, as in cases of uraemia. 
The small intestines may show areas of extreme contraction. For the 
detection of lead in urine and post-mortem specimens, the reader is 
referred to the Lancet, September 12, 1903, p. 746. 



MEDICOLEGAL SUGGESTIONS 



475 



Mercurial Poisoning. — The mucous membranes of the gastro- 
intestinal tract, particularly the small intestine and colon, especially 
near the rectum, show extensive desquamation, with hypersemia, 
ecchymoses, and grayish-white eschars. The bowel generally contains 
large quantities of a yellowish-brown or blood-stained liquid. The 
vagina may show gangrene or diphtheritic inflammation. The macro- 
scopic appearances are those of dysentery if the patient survives 
several days. In some acute cases decalcification of the bones occurs, 
with a deposit of lime elsewhere in the body, especially in the kidneys. 
The number of mercurial salts is legion, many forming with albumin 
an insoluble albuminate of mercury. Chronic cases of poisoning 
occur, ulcerative stomatitis being one of the chief lesions. Sebillotte, 
in 1 89 1, collected one hundred and forty-eight cases of poisoning 
from post-partum vaginal douches of bichlorid of mercury. He ex- 
pressed his belief that the poison was not absorbed through the 
healthy mucous membrane, but through laceration of tissue due to the 
process of labor. Hamburger, however, has found that potassium 
iodid appeared in the urine in twenty-four hours when tampons of 
cotton saturated with this substance were placed in the healthy vagina, 
and potassium ferrocyanid or salicylic acid in three hours. H. C. 
Wood, Jr., reports a case of poisoning, exhibiting hematuria, result- 
ing from the use of a douche containing 1 to 2000 of bichlorid of 
mercury. 1 

Methyl Alcohol. — Blindness or impairment of vision may occur 
not only from the ingestion of wood alcohol, but also from inhalation 
of its fumes, as methyl alcohol seems to have a predilection for the 
retina and the optic nerve. A number of cases of fatal poisoning 
from this source have recently occurred throughout America. These 
have been tabulated by Buller, of Montreal, and Wood, of Chicago. 2 

Nitrobenzol Poisoning. — Besides the odor of the artificial oil of 
bitter almonds, the blood and muscles are of a brownish color and the 
mucous membrane of the stomach is ecchymotic and injected. The body 
is cyanosed and of a leaden hue. 

Nutmeg Poisoning. — For a description of this rare but interest- 
ing form of poisoning, the reader is referred to Wallace's article in 
Vaughan's dedication volume of " Contributions to Medical Re- 
search." Grated nutmeg is used by some as an emmenagogue. 



1 Amer. Med., December 27, 1902, p. 1006. 

2 Jr. Amer. Med. Assoc, October 1, 8, 15, 22, and 29, 1904. 



476 POST-MORTEM EXAMINATIONS 

Opium Poisoning. — In acute poisoning there is nothing to distin- 
guish the condition of the brain from that in other cases of cerebral 
congestion. Extreme passive congestion of the bases of the lungs may- 
take place, as in cerebral apoplexy (Osier). Cases of uncomplicated 
chronic poisoning are rare. The most important lesion is fatty degen- 
eration of the heart. The liver may show similar changes. If lauda- 
num has been used, the characteristic odor may be present. I know 
of no drug which is more apt to escape detection at the postmortem 
than morphine, as there are absolutely no characteristic lesions and 
chemic analyses are difficult and at times inaccurate. It seems strange 
that one of the most common and easily accessible poisons is thus so 
hard to detect. The pupillary reaction is of no value after death, and 
the clotting of blood in the right heart is by no means constant. The 
blood is usually darkened, and outside of the heart it is fluid. Many, 
if not all, of the chemic tests for morphine may be simulated by the 
effect of putrefactive bodies. Kippenberger's method is not considered 
reliable by Clift. 1 As morphine gives a beautiful color with for- 
maldehyd, it is possible that the embalming of the body in a case of 
morphine poisoning might show the reaction and thus lead to the 
detection of the crime. Delearde and Ricquiet insist on the importance 
of hydrolysis with hydrochloric acid to decompose a sulphonated 
morphine derivative formed in the body and of extracting the alkaloid 
with amy lie alcohol. 

Pellagra Poisoning. — The lesions found are in the posterior col- 
umns and the crossed pyramidal tract. The cells in the anterior horn 
are deeply pigmented, and pigment is found in the internal organs and 
the skin. The brain presents general wasting; the ventricles are 
somewhat distended and contain an excess of fluid. 

Phosphorus Poisoning. — In acute phosphorus poisoning the 
gastro-intestinal tract, especially in the stomach, shows an intense 
degree of inflammation. Hemorrhages are common and the stomach 
may contain grumous (coffee-ground) blood. The mucous mem- 
brane is the seat of numerous ecchymoses as well as more or less exten- 
sive necroses. The skin, the serous membranes, the muscles, and the 
adipose tissues all show numerous small hemorrhages. The blood is 
liquid and dark. The skin is jaundiced. The liver, in the early stages 
increased in size, soon — in from six to fourteen days — becomes small 

1 Jr. Amcr. Med. Assoc, April 23, 1904. 



MEDICOLEGAL SUGGESTIONS 477 

(from one-half to one-third of the normal bulk), the capsule is wrin- 
kled and shrunken, the color is pale yellowish, and on section the organ 
presents yellowish patches in the midst of which are scattered areas of 
deep congestion, giving an angiomatous appearance to the organ ; drops 
of fat are seen upon the knife. Hemorrhages may also be seen in 
the muscles, as of the thigh. The kidneys are large, their cortex 
pale, and the medullary portions congested. The epithelium often 
shows marked granular degeneration. As a rule, the spleen is not 
markedly altered. In chronic poisoning by phosphorus wide-spread 
fatty degeneration is the rule. In cases of workers in phosphorus 
having defective teeth, necrosis of the jaw is not uncommon. It is 
the yellow phosphorus that is poisonous, and not the red variety. Bug 
exterminators often contain phosphorus. The coating from the ends 
of matches is sometimes taken with suicidal intent. 

Picrotoxin. — Carel * gives the proceedings in three cases of homi- 
cidal poisoning by picrotoxin, derived from the cocculus indicus berries 
added to the liquor of half-drunken men for the purpose of robbery 
after the production of unconsciousness. 

Potassium Chlorate Poisoning. — The blood has the color and 
consistence of chocolate, the oxyhemoglobin having been reduced to 
methaemoglobin. There is usually a hemorrhagic nephritis, especially 
of the glomeruli. Death may ensue in several hours. 

Ptomain and Toadstool Poisoning. — Such cases are of especial 
interest to the toxicologist, as the symptoms produced and the lesions 
found at the postmortem are similar to those caused by many alkaloidal 
and irritant poisons, and the possibility of the case under considera- 
tion in a trial being due to one or other of these substances is always 
suggested by the defence. 

Ricin Poisoning. — In dogs the eosinophile cells are increased in 
number. There is no marked positive degeneration of the liver, though 
the organ is congested and areas of necrosis are seen. In the kidneys 
the epithelial cells show degeneration. 2 

Silver Nitrate Poisoning. — I have been fortunate enough to 
see one case of this rare form of poisoning. The darkening of the 
necrosed mucous membrane on exposure to light was the chief diag- 
nostic point. The child had an inspiration pneumonia. 

1 Merck's Archives, July, 1904. 

2 Muller, Ziegler's Beitrage, vol. xxvii, p. 331. 



4.78 POST-MORTEM EXAMINATIONS 

Snake Poisoning. — After death caused by cobra bite rigor mortis 
occurs as usual. The areolar tissue in the region of the bite is infil- 
trated with a pinkish fluid and the vessels are injected. The blood 
presents no demonstrable change. The veins of the pia mater are 
usually engorged, and the ventricles often contain turbid fluid. The 
lungs are generally congested and the lining of the bronchi injected. 
The appearance of the kidneys varies from normal to one of intense 
congestion. After death following the bite of an Australian snake 
the appearances are much the same as those just described. The blood 
may contain soft coagula, the lungs are sometimes the seat of hemor- 
rhages, and the mucous membranes may be intensely congested and 
hemorrhagic. The blood-vessels of the central nervous system show en- 
gorgement. At autopsy, after the bite of a viperine snake, the region 
of the wound is seen to be the seat of intense oedema and extravasation 
of blood, and the underlying muscles are frequently disorganized 
and even diffluent from the latter cause. Hemorrhages may also 
be found in any of the organs and along the alimentary tract. The 
kidneys are acutely congested or hemorrhagic. The blood is fluid. 
Snake venom alone is not poisonous, but it takes a serum complement, 
like lecithin, to make it so. (Flexner and Noguchi.) Keyes 1 de- 
scribes a method of preparing a pure crystalline compound of the 
toxin. The use of cryoscopy in this and other forms of poisoning 
may prove of value. 

Strychnine Poisoning. — Rigor mortis is intense and persistent 
and the blood is dark and fluid as in asphyxia. Be sure to save the 
urine if any be present; a frog placed in it will have convulsions, even 
if but a small amount of strychnine be present. Marshall 2 reports the 
method of analysis used in a recent case with success. 

Tannin. — This substance, so useful as an antidote in various 
forms of poisoning, may itself produce violent diarrhoea and vomiting. 

1 Berl. klin. Wchnschr., 1903, nos. 42 and 43. 

2 Amer. Med., June 18, 1904. 



CHAPTER XXIX 

THE PRUSSIAN REGULATIONS FOR THE PERFORMANCE OF AUTOPSIES 
IN MEDICOLEGAL CASES 

The Prussian regulations governing the performance of postmor- 
tems by the legally appointed officers of the Court are of great historic 
interest, as they bear the imprint of Virchow, and, though put in force 
February 13, 1875, are st i^ observed throughout Prussia. These regu- 
lations also form the basis of similar statutes in other German states 
and in many countries throughout the world ; indeed they are so well 




Fig. 201. — Bronze medal of Rudolph Virchow ; Virchow Jubilee, Berlin, 1892. (From one of the medals 
presented to the College of Physicians of Philadelphia, by S. Weir Mitchell, M. D. Reduced.) 

defined that it is advisable, though one may chafe under their appar- 
ently unnecessary restrictions, to depart from them only in exceptional 
instances. This is especially the case if the one performing the autopsy 
is a beginner in medicolegal work. 

479 



4 8o POST-MORTEM EXAMINATIONS 

I. GENERAL CONSIDERATIONS. 

\ i. According to the present law, an examination of a corpse 
makin^theTuto s f ° r medicole S al purposes may be made only in the presence of 
and their Duties ' a magistrate by two practitioners, one of whom should be a 

state-appointed physician and the other a district surgeon. Upon 
those performing the autopsy devolve the duties of medicolegal experts. If doubt 
should arise in the technical performance of the autopsy, the physician or his deputy 
decides the question under consideration conditionally upon the right of the surgeon 
to state upon the protocol his dissenting opinion. 

Substitutes ^ 2 ' The medical officers are permitted to appoint substitutes 

only when legitimately detained from the performance of their 
medicolegal duties. If possible, the deputy chosen is to be a physician who has 
passed his pro physicatu examination. 



Time after Death 
at which the Post 



I 3. As a rule, postmortems should not be performed until 
twenty- four hours after death; the mere inspection of a corpse, 
mortem is to be however, may be made earlier than this. 

performed 

1 4. Generally, post-mortem examinations must not be neg- 
The Examination of lected nor their performance refused by the legally appointed 
Decomposed Bodies physicians because of the presence of decomposition, for even in 

a badly decomposed cadaver abnormalities and injuries to the 
bones may still be detected; many facts of value in the identification of a body 
may be ascertained, such as the color and appearance of the hair, the absence of 
limbs, etc.; and substances which have entered the body from without may be 
discovered, as well as pregnancy or poisoning proved. On the same grounds, 
when for one reason or another the advisability of disinterring a body is under 
consideration, the physicians are to approve of such exhumation without regard to 
the time which has elapsed since death. 

2 5. The legally appointed physicians are to be careful to have 

Instruments , - „ . . f ,. , . , ... 

the following instruments in readiness and in good condition : 

from four to six scalpels, of which the two smaller ones are to possess a straight and 
the two larger ones a rounded cutting edge ; one razor ; two strong cartilage-knives ; 
two forceps ; two double hooks ; two pairs of scissors, — the stronger pair should 
have one blade pointed and the other rounded, while the smaller pair should possess 
one probe-pointed and one sharp-pointed blade; one enterotome; one injecting 
nozzle with stopcock ; one coarse and two fine sounds ; one saw ; one chisel and one 
hammer ; one costotome ; six curved needles of different sizes ; one pelvimeter ; a 
one-metre rule divided into centimetres and millimetres ; a measuring-glass divided 
into one hundred, fifty, and twenty-five cubic centimetres ; one pair of scales capable 
of weighing up to ten pounds ; one good magnifying-glass ; blue and red litmus 
paper. The cutting instruments must be perfectly sharp. Those performing the 
postmortem are recommended to have ready for use a microscope with two objec- 
tives, so as to be able to magnify at least four hundred diameters, and the required 
instruments, glassware, and reagents necessary for the preparation of microscopic 
slides. 



PRUSSIAN MEDICOLEGAL POSTMORTEMS 48 1 

§ 6. A sufficiently large, well-lighted room is to be chosen for the 

autopsy, and all possible care is to be taken in the selection of place for the Autopsy 

a suitable place on which to lay the body and in the avoidance an d its Lighting 

of all disturbing surroundings. Post-mortem examination by 

artificial light, except where postponement is impracticable, is not allowed; should 

it be done, the reason therefor must be expressly stated in the protocol ($27). 

§ 7- If the body be frozen, it must be brought into a heated 
place and the autopsy postponed until the cadaver has sufficiently 
thawed ; the employment of warm water or other warm articles to hasten the thaw- 
ing process is forbidden. 

§8. If possible, when for any reason the body is moved, espe- 
cially if transported from one place to another, there is to o/^pses ^ 
be no excessive pressure made upon any of the individual parts, 
nor any marked departure from the horizontal position of the organs in the larger 
cavities. 

II. TECHNIC OF THE POSTMORTEM. 

§ 9. Those performing the postmortem must hold steadfastly 

to the object in view, which is to make the investigation with f e t he°postaiortem S 

accuracy and completeness. All important findings must be 

shown to the magistrate by the obducents before they are entered in the protocol. 

§ 10. In those cases in which this appears to be necessary, the Duties of the Obdu- 
examiners are required, as early as feasible before the perform- cents in regard to 
ance of the autopsy, to ask the magistrate for permission to visit the Ascertainment 

, , r 1 1 1 .of Special Circum- 

the place where the body was found, and they are to ascertain stances connected 
the position in which the body was discovered and be given an with the Case 
opportunity to examine the clothing which the deceased wore under investigation 
at the time of death. As a rule, however, it is sufficient for them to await 
the solicitation of the magistrate to undertake these investigations. They are 
also obliged to ask for information from the magistrate in regard to any disclosures 
which might be of use to them in the performance of the autopsy or in helping 
them to make up their deductions therefrom. 

\ 11. In cases in which a doubtful finding is to be quickly 

and definitely settled, — as, for example, the differentiation be- Microscopic 

tween blood and a fluid which is merely stained with haematin, — 

a microscopic examination is to be then and there undertaken. When circumstances 

render this impossible or when there are required difficult microscopic investigations 

which cannot be made at once, — as, for example, of certain tissues of the body, 

— portions of such tissue are to be preserved under legal protection and as 

quickly as possible thereafter to be thoroughly examined. It is to be distinctly stated 

in the report of such findings when the examinations were performed. 

\ 12. The postmortem is divided into two main parts : A. Exter- 
nal examination (inspection). B. Internal examination (sec- two main division * 
tion). 

§ 13. In the external inspection of the body its appearance in External 
general and that of its individual parts in particular are to be Exami nation 
noted. In this general examination of the body the following 
points, in so far as possible, are to be brought out and recorded. 1. Sex; age; 

3i 



482 POST-MORTEM EXAMINATIONS 

size ; development ; general condition of nutrition ; any signs of previous illnesses, 
— e.g., ulcers of the foot ; special abnormalities, — e.g., moles, scars, tattoo markings ; 
supernumerary or absent limbs. 2. The signs of death and the changes that have 
already taken place from decomposition. 

After removal by washing of any contaminations of the body in the way of 
blood, faeces, dirt, etc., record is to be made of the presence or absence of post- 
mortem rigidity; the general color of the skin of the corpse; the kind and degree 
of coloration and discoloration brought about by putrefaction; and the color, 
situation, and extent of any areas of hypostatic congestion, which are to be incised 
and then carefully examined and described, in order to prevent their being mistaken 
for extravasations of blood. 

The following particulars are to be considered in the study of the individual 
parts. 1. In unidentified persons, the color and other appearances of the hair 
(head and beard), as well as the color of the eyes. 2. The possible presence of 
foreign substances in the normal openings of the head, the arrangement of the 
teeth, and the situation and appearance of the tongue. 3. An examination is next 
to be made of the neck, the breast, the abdomen, the back, the anus, the external 
genitalia, and finally of the limbs. 

If an injury is found in any of these parts, its shape, situation, and direction 
with relation to fixed points of the body are to be described and the length and 
breadth of the injury given in the metric system. In solution of continuity of 
tissue, probing is, as a rule, to be avoided in the external inspection, because after 
the internal examination of the body and of the injured spot the extent of the 
injury becomes apparent. Should the obducents decide that the introduction of 
a sound is necessary, this procedure is to be done with great care, and special 
mention of the reason therefor is to be made in the protocol ( g 27) . When wounds 
are present, a description of their borders and the adjacent tissues is to be given, 
and after such an examination and description of the lesions in their original con- 
dition the same are to be enlarged in order that the internal appearance of the 
borders and of the bottom may be disclosed. As to wounds and injuries which 
clearly did not conduce to, originate from, or have any connection with death, — for 
example, markings produced in the endeavor to restore life, gnawing by animals, and 
the like, — a summary description of the findings is sufficient. 

I 14. In the internal examination the three main cavities of the 
internal Examina- j^y — ^ ^^^^ the thoracic, and the abdominal — are to be 
Considerations opened. Opening of the vertebral column or of the individual 

joints is not to be omitted in cases where important findings 
might be secured thereby. When there is a definite suspicion as to the cause of 
death, the postmortem is to be commenced with that cavity in which the chief 
changes are suspected. Otherwise the head is to be examined first, the thorax 
next, and the abdominal cavity last. 1 The situation of the organs found in each 
of the above-named cavities is first to be determined, then the color and the appear- 
ance of the exposed surfaces. The presence is to be noted of any unusual con- 
tents, such as foreign bodies, gases, fluids, or clots, and in the last two cases 
measured and weighed, and finally each individual organ is to be examined exter- 
nally and internally. 



1 As to autopsies on the new-born see §§23 and 24. 



PRUSSIAN MEDICOLEGAL POSTMORTEMS 483 

B 15. When no injuries are present, the opening of the cranial ., . , „ . 

• ^ • ,• , , , , • .... . Cranial Cavity 

cavity is accomplished by making an incision from one ear to the 

other directly over the skull, after which the skin-flaps are displaced forward and 
backward. (In case injuries are present, they should be as much as possible circum- 
vented by the knife, thus giving rise to a different procedure.) As soon as the 
appearance of the soft parts and the surface of the bony cranium has been described, 
the latter is cut through with a saw by a circular incision, and the section, the inner 
table, and the other appearances of the calvarium are described. The external sur- 
face of the dura mater is next examined, the longitudinal sinus opened, and its 
contents estimated. The dura mater is then to be separated on one side and laid 
back, and the internal surface of the same described, as well as the appearance of the 
exposed pia mater. After this has been done on the opposite side, the brain is to be 
removed in as perfect a condition as possible, and the presence of abnormal contents 
in the skull is to be noted, and the appearance of the dura and pia mater at the base 
and sides of the skull and the condition of the large arteries are to be described. 
After the opening of the transverse sinuses (and, in case reason therefor exists, of 
the remaining sinuses), the size and shape of the brain are noted and an examination 
is made of its individual parts by means of a series of well-ordered incisions. Such 
parts include both cerebral hemispheres, the large ganglia (optic thalamus and 
corpus striatum), the corpora quadrigemina, the cerebellum, the pons Varolii, and 
the medulla oblongata, in the description of which are to be included especially the 
color, the fulness of the vessels, the consistency, and the structure. In addition, the 
tissue and the vessels of the choroid plexus are always to be described. The size 
and the contents of the different ventricles as well as the appearance and fulness of 
the different vascular plexuses in the individual sections of the brain are constantly 
to be kept in mind, and especial note is to be made of the presence of any clotted 
blood outside of the blood-vessels. The dura mater over the base of the skull and 
the sides is then to be removed and the condition of the bones in these regions 
described. 

\ 16. When it is required to open the internal portions of the 

face, to examine the parotid gland, or to inspect the auditory Glan ^ nd E 

apparatus, the initial incision extending over the skull is continued 

behind the ear and down the neck, and the skin, for appearances' sake, is dissected 

away from beneath towards the part to be investigated. In this examination special 

attention is to be paid to the condition of the large arteries and veins. 

\ 17. The opening of the spinal column (§ 14) is usually made 
from behind, the skin and the subcutaneous fatty tissue being cut ^ n * ? umn 
directly over the spinous processes and the musculature dissected 
away from the side of the latter and from the vertebral arches. During this exam- 
ination hemorrhages, lacerations, and similar changes, especially fractures of bones, 
are to be carefully searched for. Then a chisel, or, if one is at hand, a vertebral 
saw (rhachiotome) is used for the purpose of separating the spinous processes with 
the adjacent portions of the arches throughout their entire extent. When they are 
removed, the external surface of the dura mater, which is now brought into view, 
is examined. It is next to be carefully opened by means of a longitudinal incision, 
and any abnormal contents, especially fluid or extravasated blood, are to be described, 
also the color, appearance, and similar characteristics of posterior portions of the 
pia mater, and by means of a gentle passage of the fingers over the spinal cord its 
degree of consistency is to be determined. Next, on both sides, by means of a 



4 8 4 POST-MORTEM EXAMINATIONS 

longitudinal incision the nerve-roots are cut through ; then with one hand the lower 
end of the spinal cord is carefully grasped, and, after dividing the anterior attach- 
ments one after another, its upper end is finally drawn out of the occipital foramen. 
In all these proceedings special care should be taken not to make pressure on the 
spinal cord or to bend it. When the cord has been removed, the anterior surface 
of the pia mater is to be examined ; next the external appearance of the cord as 
to size and color is to be described, and finally, by a considerable number of trans- 
verse incisions with a sharp and thin knife, the internal appearance of the spinal 
cord, both as to its white and its gray matter, is to be noted. Finally the dura 
mater of the vertebral bodies is to be removed, and they are to be examined in 
order to determine if there have been any hemorrhages, injuries, or changes in the 
bones or in the intervertebral discs. 

\ 18. The neck and the thoracic and abdominal cavities usually 
Neck, Thoracic and are opened by means of a single long incision from the chin to 
GenrrTrcon^Mera 6 - 5 ; the pubic symphysis, passing to the left of the navel. Most 
tions commonly the incision in the abdomen is made deep enough to 

penetrate the abdominal cavity, care being taken to avoid injuring 
the organs contained therein. This is best begun by cutting a small nick in the 
peritoneum, at the same time observing whether any gas or fluid escapes. One 
finger is introduced into the opening and then another, the abdominal wall is ele- 
vated from the intestines, and the further opening of the peritoneum is made 
between the two fingers. The situation, the color, and other appearances of the 
intestines are to be immediately observed, as well as any abnormal contents within 
them, and the condition of the diaphragm is to be determined by palpation of its 
under surface. 

The examination of the abdominal organs is to be proceeded with at this time 
only where a strong suspicion exists that the cause of death may be found within 
the abdomen ($14). As a general rule, the thorax is to be opened and inspected 
before any further scrutiny of the abdominal cavity is done. 

I 19. In opening the thoracic cavity the soft parts of the breast 
Thoracic Cavity are dissected slightly beyond the junction of the osseous and 

cartilaginous portions of the ribs. Next with a strong knife 
the cartilages are incised a few millimetres within their attachment to the ribs, 
care being taken to avoid cutting the lungs or the heart. If the cartilages be ossi- 
fied, the ribs are to be separated with a saw or a costotome somewhat beyond the 
cartilaginous junction. The attachments of both clavicles to the sternum are then 
separated by vertical semicircular sections, and the junction of the first rib, be it 
cartilaginous or ossified, is loosened with the knife or costotome, great care being 
taken to avoid injuring the vessels which lie beneath. The diaphragmatic attach- 
ments along the line of incision are severed close to the false cartilages and the 
ensiform process. The sternum is turned upward and the mediastinum is cut 
through, with careful avoidance of any injury to the pericardium or the large 
blood-vessels. When the sternum has been separated, the condition of the pleural 
cavity is to be determined, especially as to any abnormal contents, which are to be 
measured and their characteristics described; also the extent and the appearance 
of any portions of the lung which are in view. If any vessels have been injured 
in the removal of the breast-bone, they are to be tied or a sponge is to be placed 
beneath the bleeding points to catch the blood which if it were allowed to enter 
the pleura would later obscure the observation of the parts therein. The condition 
of the mediastinum and especially that of the thymus gland are to be noted, as well 



PRUSSIAN MEDICOLEGAL POSTMORTEMS 



485 



as the appearance of the large blood-vessels lying outside of the pericardium, which 
are not yet incised. The pericardium is next to be opened and examined and the 
exterior of the heart inspected. Before the heart is incised or removed from the 
body its size, the filling of the coronary vessels and its individual cavities (auricles 
and ventricles), its color, and its consistency (rigor mortis) are to be estimated. 
While the organ is still in its natural position, the ventricles and auricles are to 
be separately opened and the contents of each chamber determined as to their 
amount, coagulation, and appearance, and the dimensions of the auriculoventricular 
openings are to be ascertained by the introduction of two fingers through the auricle. 
The heart is then to be removed from the body and the condition of the arterial 
vessels tested, first by filling them with water and next by incising their walls. 
Finally the color and exact appearance of the heart muscle are to be described. 
In every case wherein it is suspected that extensive changes — e.g., fatty degeneration 
— have occurred in the muscular tissue a microscopic investigation is to be made. 
To this examination belongs that of the large vessels, with the single exception of 
the descending aorta, which is to be examined after the lungs have been excised. 
A minute inspection of the latter is not undertaken until they have been removed 
from the thoracic cavity. During this procedure great care is to be taken to 
avoid tearing or pressing upon the tissues. Should there be any extensive, espe- 
cially old, adhesions, these are not to be broken down, but the attached pleura 
at this point is to be excised at the same time. When the lungs have been removed, 
their surface is again to be carefully examined for recent changes, so that nothing 
shall be overlooked, — for example, the commencement of inflammatory exudations ; 
then the air contents, color, and consistency of the individual lobes are to be given. 
Finally large, smooth sections are to be made in order to determine the appearance 
of the cut surface and the air, blood, and fluid contents, as well as any solid con- 
tents of the air-vesicles, the condition of the bronchi and the pulmonary arteries, 
the latter being examined with special care to detect any obstructions, etc. For this 
purpose the air-passages and the large pulmonary vessels are to be opened with 
scissors and their finer ramifications followed out. When the suspicion arises that 
foreign materials are present in the air-passages or substances are therein found the 
nature of which cannot with certainty be determined by the naked eye, a micro- 
scopic examination is to be made. 

\ 20. The examination of the neck may, according to the nature 
of the case, be made either before or after the opening of the 
thorax or the removal of the lungs. The obducents may also sever the larynx and 
the bronchus before the further inspection of the remaining parts when it seems to 
them especially desirable so to do, as is the case in drowning or hanging. As a 
rule, it is wise first to examine the large vessels and the nerve-trunks, then the 
larynx and trachea, by means of an anterior incision, and note their contents. If 
this observation should appear to be of especial importance, it is to be made before 
the removal of the lungs, which are at the same time to be carefully pressed upon 
to see if any fluid, etc., arises in the trachea. The larynx, the tongue, the velum 
palati, the pharynx, and the oesophagus are to be removed together; the individual 
parts are to be entirely opened and their contents and especially the mucosa thor- 
oughly examined. At the same time the thyroid, the tonsils, the salivary glands, and 
the lymph glands of the neck are to be observed. In every case where injuries of the 
larynx or of the bronchus have been found or important changes therein are sus- 
pected, the air-passages are to be opened after their removal from the body and 
they are then to be examined from their posterior aspect. In cases of hanging or 



4 85 POST-MORTEM EXAMINATIONS 

in suspicious cases of strangulation the carotids are to be opened in order to ascer- 
tain whether or not their inner coats have been injured. This examination is to 
be undertaken while the vessels are still in their natural situation. Finally the condi- 
tion of the cervical vertebrae and of the deep musculature is to be determined. 

$ 21. The abdominal cavity and its viscera are now to be critically 
Abdominal Cavity inspected in such order that the removal of one organ does not 

prevent the exact determination of its relations to another. Thus, 
the duodenum and the gall-ducts are to be examined before the scrutiny of the liver. 
As a rule, the following order of examination commends itself: I. Omentum. 2. 
Spleen. 3. Kidneys and adrenals. 4. Bladder. 5. Organs of generation : in the 
male, prostate, seminal vesicles, testicles, and penis with the urethra; in the female, 
ovaries, Fallopian tubes, uterus, and vagina. 6. Rectum. 7. Duodenum and stomach. 
8. Gall-ducts. 9. Liver. 10. Pancreas. 11. Mesentery. 12. Small intestine. 13. 
Large intestine. 14. The large blood-vessels in front of the vertebral column, whose 
condition as to blood contents is to be ascertained and noted. 

„ , In every case the spleen is examined in regard to its length, 

breadth, and thickness, not while held in the hand, but when 
placed on a solid surface and without pressure by the instrument used in measuring. 
It is to be divided throughout its entire length, more incisions being made in different 
directions if diseased areas are found. 

Each of the kidneys is to be removed after cutting vertically 

through the peritoneum externally and behind the ascending or 
descending colon, which is shoved back. The capsule is then incised longitudinally 
through its convex border and slowly peeled off, and the exposed surface of the 
kidney is examined in regard to size, form, color, condition of blood, and other 
appearances. Next a longitudinal incision is made through the entire kidney to its 
pelvis, and the cut surfaces are washed with water and described, in which descrip- 
tion medullary and cortical substances, vessels, and parenchyma are to be distin- 
guished. 

The pelvic organs (bladder, rectum, and genitalia connected 
Pelvic Organs therewith) are removed preferably en masse, the bladder being 

opened and its contents examined while it is still in its natural 
situation. After their removal they are again inspected, the reproductive organs 
being examined and opened last. The slitting of the vagina is to precede that of the 
uterus. In puerperas the venous and lymphatic vessels, both in the internal surface 
of the uterus and in its walls and adnexa, require special attention as to their width 
and contents. 

When their external condition has been determined, the stomach 

Stomach and . , , . . ... , . , . , 

Duodenum anc * duodenum are with a pair of scissors opened in their natural 

situation, the duodenum on its anterior surface and the stomach 
along its greater curvature. After a careful inspection of their contents, the per- 
meability and the presence of any matter in the opening of the gall-passages are 
determined and these parts are then removed for further examination. 

Liver The liver is first described externally in its natural situation, and 

after its secretory ducts have been examined (as mentioned in 
the preceding paragraph) the gland is excised. Smooth incisions are now made 
through the entire length of the organ and its capacity for blood and the condition 
of the parenchyma determined. In the description a short account is always to be 
given of the general relations of the individual lobes, noting especially the condition 
of the inner and outer portions. 



2 n 

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PRUSSIAN MEDICOLEGAL POSTMORTEMS 4 8~ 

The small and large intestines, after their individual portions 
have been examined externally as to dimensions, color, and other Small and Large 
peculiarities worthy of mention, are removed together, their Intestines 
mesenteric attachments being severed with a knife close to the 
bowels, which are then opened with a pair of scissors at the place where the mesen- 
tery was attached. During these incisions the contents of the several parts are 
observed and described. Next the intestines are cleansed and the condition of the 
individual portions, especially of the small intestine., is inspected with special regard 
to the Peyer's patches, the solitary follicles, the villi, and the intestinal folds. At 
least in every case of inflammation of the peritoneum the appendix is to be carefully 
examined. 

i 22. In those cases in which poisoning is suspected the internal 
examination is to begin with the abdominal cavity. Before any- Cases of Poisoning 
thing else is done the external appearance of the upper abdominal 
viscera, their situation and extent, the filling of their vessels, and the presence of 
any odor are to be determined. In regard to the vessels, here as in other important 
organs, we are to ascertain whether we are dealing with arteries or veins, whether 
only the main trunks and their branches or the smaller ramifications also are filled to 
a given degree, and whether the extent of the vascular thinning is considerable or 
otherwise. Then to the portion of the cesophagus just above its entrance into the 
stomach and to the duodenum just below the entrance of the gall-duct double liga- 
tures are to be applied and both parts incised between them. Next the stomach with 
the duodenum attached is carefully removed from the body and opened in the 
manner described in § 21. The contents are immediately examined as to their 
amount, consistency, color, composition, reaction, and odor, and placed in a clean 
porcelain or glass vessel. Then the mucosa is washed and its thickness, color, 
surface, and condition are determined, the state of the blood-vessels and the struct- 
ure of the mucous membrane being particularly noted and each main portion 
separately described. Of especial importance is it to ascertain whether the blood 
which is present lies within the vessels or is exuded therefrom, whether it is fresh 
or changed by decomposition or by digestion, and whether in these conditions the 
neighboring tissues are permeated therewith. If such imbibition has occurred, it is 
to be noted whether it is found only upon the surface or in the tissue also, whether 
it is coagulated or not, etc. Finally it is of especial importance to decide, in the 
inspection of the surface, whether loss of substance, erosions, and ulcers are present. 
The question whether certain changes might not have resulted from natural processes 
of decomposition after death, especially from the action of the fermentative juices 
of the stomach, is always to be considered. After the completion of this examina- 
tion, the stomach and duodenum are to be placed in the same vessel with the gastric 
contents (see above) and given to the magistrate for further investigation. An 
anatomic examination having been made of the cesophagus, it is tied high up in 
the neck, severed above the ligature, and placed in the same vessel. In those cases 
in which but a small amount of stomach contents is present the contents of the 
jejunum are also to be preserved. Finally other substances and portions of organs, 
as blood, urine, pieces of the liver and of the kidney, etc.. are to be removed from 
the body and given to the magistrate for further examination. The urine is to be 
placed in a separate vessel, and the blood is to be preserved separately only in those 
cases where spectroscopic examination might disclose facts of interest. All of the 
remaining portions are to be placed together in a single receptacle. Each of these 
vessels is closed, sealed, and labelled. In every case where the macroscopic ex- 



4 gg POST-MORTEM EXAMINATIONS 

animation shows special alteration and swelling of the mucous membrane of the 
stomach, a microscopic examination thereof is to be made as soon as possible, 
especial attention being given to the condition of the peptic glands. Whenever 
suspicious bodies are found in the stomach contents, as portions of leaves or other 
parts of plants, remnants of animal food, etc., these also are to be viewed with a 
microscope. Where trichinosis is suspected, not only a microscopic examination 
of the contents of the stomach and of the upper portion of the small intestine is to 
be made, but portions of muscular tissue from the diaphragm, the neck, and the 
thorax are also to be laid aside for future study. (Fig. 202.) 

\ 23. In postmortems on the new-born, besides the points pre- 
The New-born; viously given, there are to be determined, first of all, the data 

Determination of the n which the ma turity and the intra-uterine developmental 

Maturity and Period . 

of intra-uterine period of the child depend. For these purposes consider the 

Gestation length and weight of the body, condition of the general coverings 

and of the umbilical cord, length and appearance of the hair of 
the head, size of the fontanels, longitudinal, transverse, and diagonal measurements 
of the head, appearance of the eyes (pupillary membrane), condition of the nasal 
and auricular cartilages, length and characteristics of the nails, transverse diameter 
of the shoulders and hips ; in boys the condition of the testicles and the appearance 
of the scrotum, and in girls any peculiarities of the external genitalia. It still 
remains to be noted whether there be present, and if so to what extent, an ossifying 
centre in the inferior epiphysis of the femur. To determine this the patella is 
removed through a horizontal incision made just below it while the knee-joint is 
strongly flexed, and thin transverse sections are made continuously through the 
cartilage until the greatest transverse diameter of any centres of ossification which 
may there be present is found, which is then to be measured in millimetres. 
When from an examination of the offspring it seems to have been born before the 
thirtieth week, the postmortem may be discontinued unless a special request is given 
by the magistrate for its completion. 

\ 24. If it be determined that the child was born after the thir- 
The Determination tieth week, the following data must be obtained in order to 
the Child h decide whether it breathed during or after birth. For this pur- 

breathed P ose the respiratory tests are to be applied in the following order : 

(a) Immediately after the opening of the abdominal cavity the 
condition of the diaphragm in relation to the corresponding ribs is to be determined. 
Hence in every case of examination of the new-born the abdominal cavity is to be 
opened first and afterwards the thoracic and cranial cavities. 1 (b) Before opening 
the thoracic cavity the trachea is to be once ligatured above the sternum, (c) The 
thoracic cavity is next to be opened and the extent and consequent situation of the 
lungs, the latter especially in regard to the pericardium, determined, and also the 
color and consistency, (d) The pericardium is to be incised and both its condition 
and the external appearance of the heart are to be described, (e) The individual 
cavities of the heart must be laid open, their contents noted, and other appearances 
determined, (f) The larynx and the portion of the trachea above the ligature are 
to be slit, and their contents as well as the appearance of their walls determined. 
(g) The trachea is to be cut through above the ligature and removed in connection 
with the other organs of the thorax, (h) After the removal of the thymus gland and 

1 But in no case shall section of the organs of the abdominal cavity be undertaken before the opening 
and examination of those of thet horax. 



PRUSSIAN MEDICOLEGAL POSTMORTEMS 489 

the heart, the lungs are to be tested as to whether or not they float in a large vessel 
rilled with pure cold water, (i) The lower portion of the bronchus and its branches 
are to be opened and their contents specially examined. (/) Incisions are to be made 
into both lungs, the presence or absence of crepitation being carefully noted as well 
as the amount and appearance of any blood which may exude under slight pressure 
upon the cut surfaces, (k) The lungs are also to be incised under water in order to 
determine if any air-bubbles arise from the cut surfaces. (/) The lobes of both 
lungs are next to be cut apart, each lobe subdivided, and every separate portion tested 
as to its sinking or floating in water, (m) The oesophagus is to be opened and its 
condition ascertained, (n) Finally, in those cases where it is suspected that the 
pulmonary tissues may have been filled with the products of disease (hepatization) 
or with foreign bodies (vernix caseosa and meconium), so as not to permit of the 
entrance of air, the same are to be examined microscopically. 

§ 25. Finally, it is the duty of the obducents to examine all 

organs not mentioned in these regulations in case injuries or Examinations 

other abnormalities are discovered. 



Closure of the Body 



§ 26. The district surgeon, with the second physician acting as 
a consultant, is required, after the ending of the autopsy and as 
far as possible the removal of waste, to undertake the proper closure of those cavi- 
ties of the body which have been opened. 



III. THE DRAWING UP OF THE PROTOCOL OF THE POSTMORTEM 
AND THE FINAL REPORT OF THE SAME. 

$ 27. A post-mortem protocol is to be made by the magistrate, 
at the time and place of performing the autopsy, concerning all Pr o toc °i ~ m ° 
matters relating thereto. The medical officer must, therefore, 
be careful that the technical findings which have been determined at the examination 
are faithfully recorded in the protocol. In order to accomplish this, it is recom- 
mended to the magistrate that the description and findings of each individual organ 
be written down before another part is examined. 

\ 28. The technical findings given in the post-mortem protocol 
by the medical officer must be stated clearly, definitely, and in Arrangement and 
such a manner as to be understood by one who is not a physician ; Form of the Protocol 
for this purpose the use of foreign expressions is to be avoided 
except where these may be needed to make clear the description of the findings. 
The chief divisions, the external and internal examinations, are to be designated 
with capital letters (A and B). The findings for the openings in the cavities are 
to be given, in the order in which they were examined, with Roman numerals (I, 
II) ; but the organs in the thorax and abdominal cavity are to be entered under a 
single number. The descriptions of the organs of the thorax and abdominal cavity, 
named in § 18, are to be designated by the letters a and b. The results of the 
examination of each individual part are to be designated with Arabic numerals, 
such numbers running consecutively from the beginning to the end of the protocol. 
The record of the examination must be given in the protocol with special reference 
to the actual observations, and not in the form of mere statements of opinion, — as, 
for example, inflamed, gangrenous, healthy, normal, wound, ulcer, and the like. The 



49 POST-MORTEM EXAMINATIONS 

obducents have the option, however, in those cases in which it seems necessary for 
clearness, to add such observations, inclosed in parentheses. In every case a note 
must be made of the blood contents of each important part, and a short description 
thereof must be given, and not simply a name, — as considerable, moderate, middling 
amount, much reddened, rich in blood, poor in blood. Before any part is incised its 
size, form, color, and consistency are to be noted, in the order here named. 

£ 29. At the close of the postmortem the obducents are to give 
Provisional Opinion in the protocol their provisional opinion of the case, without 

stating their reasons therefor. If anything be known by means of 
which the diagnosis is influenced, in the way of previous history or the like, this 
must be briefly noted. Should the magistrate ask any special questions, the answers 
should be distinctly entered in the protocol, with the statement tnat they are given 
at his request. In every case the opinion as to the cause of death is to be stated, 
first with special reference to the facts bearing on the objective findings and then 
as to the question of criminal motive. If the cause of death is not determined, this 
fact must be recorded. It is never sufficient to say that death resulted from 
internal causes or from disease. The latter, whatever it is, must be specifically 
named. Special mention is to be made, with the reason therefor, in cases where 
further technical examinations are needed or where doubtful conditions exist. 

I 30. Should injuries be found on the body which were presuma- 
Supplemental ^j t k e cause f d ea th, and if suspicion be aroused that a specially 

Observations on ,. . . . _. . . , 

Instruments discovered instrument might have inflicted such injuries, the 

obducents, at the request of the magistrate, are obliged to investi- 
gate and to express an opinion as to whether any and, if so, what injuries might have 
been caused by the instrument, and what conclusions from the situation and appear- 
ance of the wound are to be drawn as to the manner in which the one performing the 
act might have committed the deed, and also as to the strength with which it was 
performed. When definite weapons are not found, the obducents, as far as it is 
possible from the conditions present, are to give their opinion as to how the injuries 
were caused and especially as to what instruments might possibly have been used. 

$ 31. If the obducents be requested to present a report, this should 
Post-mortem Report be introduced without useless formalities by a condensed but 

exact review of the case, with the conclusion reached by them and 
the facts on which it is based. Then so much of the post-mortem protocol as they 
think necessary for the explanation of the case is to be given verbatim, with the 
number of the protocol. Any change made therein must be expressly stated. The 
style of the post-mortem report must be plain and concise, and the proof which led 
to the formation of the opinion therein expressed so set forth as to be understood by 
and convincing to one not a physician ; for this purpose, the obducents are to use, as 
far as possible, German expressions and ordinarily accepted meanings. Especial 
attention to literary sources of knowledge is, as a rule, to be avoided. When as 
medical experts the obducents are asked certain questions by the magistrate, these 
are to be answered fully and as directly as possible, or, if this cannot be done, the 
reasons therefor are to be given. 

Both obducents must sign their report, which must also bear the official seal of 
the district physician if he has taken part in the autopsy. When such a post-mortem 
account is requested, it must be delivered by the obducents within four weeks at 
the latest. 



CHAPTER XXX 

USUAL CAUSES OF DEATH : THEIR NOMENCLATURE, COMPLICATIONS., 

AND SYNONYMS 

As morbidity and mortuary statistics are intimately associated 
the one with the other, uniformity in their nomenclature throughout 
the world is greatly to be desired. At the Eighth International Con- 
gress of Hygiene and Demography, held in Paris, August 18 to 21, 
1900, a modification of the old Bertillon classification was adopted and 
called the " International System of Nomenclature of Diseases and 
Causes of Death." x It is here added but slightly altered in a few 
minor particulars as to the causes of death. 

I. GENERAL DISEASES. 

1. Typhoid Fever (Abdominal Typhus). Include: Dothienenteritis ; mucous, 

continued, enteric, ataxic, or adynamic fever ; abdominal typhus. — Do not 
include: Adynamia (179) ; ataxo-adynamia (179). — Frequent complications: 
Pneumonia ; pulmonary congestion ; intestinal perforation ; peritonitis ; in- 
testinal hemorrhage ; sloughing ; albuminuria. 

2. Exanthematous Typhus. 2 Include: Petechial fever; petechial typhus. — Do 

not include: Abdominal typhus ; typhus. 

3. Relapsing Fever. Include: Recurrent fever ; recurrent typhus. 

4. Intermittent Fever and Malarial Cachexia. Include: Paludal fever; per- 

nicious fever ; accesso pernicioso; remittent fever; malaria; ague; etc. 
4a. Malarial Cachexia. Include: Paludism; pernicious cachexia, etc. 

5. Smallpox. Include: Variola, varioloid. — Do not include: Varicella (19). — 

Frequent complications: Meningitis; endocarditis; suppuration; albuminuria. 

6. Measles. Include: Eruption of measles; morbilli. — Do not include: Rubeola 

or German measles (19). — Frequent complications: Bronchitis; broncho- 
pneumonia. 

7. Scarlatina. Include: Puerperal scarlatina; scarlatinous angina. — Frequent 

complications: Albuminuria; eclampsia; oedema of the glottis; hemor- 
rhage ; endocarditis ; pericarditis ; paralysis ; convulsions ; diphtheria. 

8. Whooping Cough (Pertussis). Frequent complications: Bronchitis; spasms. 

9. Diphtheria and Croup. Include: Diphtheritic, buffy, pseudomembranous, 

infectious, malignant, or toxic angina. Diphtheria under all its forms, espe- 
cially diphtheria of wounds, cutaneous diphtheria; conjunctival diphtheria; 

1 Supplement to Public Health Reports, vol. xv, no. 49. Translated by Passed Assistant Surgeon 
H. D. Geddings. William A. King, chief statistician of vital statistics of the United States Census, 
has added to this list the indefinite and unsatisfactory synonyms used for causes of death in the returns to 
the United States Census Office for 1890 and 1900. Washington, 1902. 

2 The word "typhus," without qualification, will be taken in the sense which is usual to it in each 
country, — viz., in the sense of " abdominal typhus" in German-speaking countries, or as " exanthematous 
typhus" in French-speaking ones. 

491 



492 POST-MORTEM EXAMINATIONS 

buccal diphtheria; pseudomembranous bronchitis; pseudomembranous lar- 
yngitis; malignant laryngitis; diphtheritic paralysis, etc. — Do not include: 
Stridulous croup (88) ; spasmodic croup (88) ; faise croup (88). — Frequent 
complications: Pneumonia; albuminuria; paralysis. 
9a. Diphtheria. 

io. Influenza. Include: Grippe; grippal pneumonia; grippal bronchitis; epi- 
zootic ; and grippal bronchopneumonia. 

ii. Sweating or Miliary Fever. Include: Sudor. 

12. Asiatic Cholera. Include: Indian cholera; cholera (when epidemic); epi- 

demic cholera. 

13. Cholera Nostras. 1 Include: Sporadic cholera; cholerine; choleriform en- 

teritis or diarrhoea ; cholera (when not epidemic). — Do not include: Cholera 
infantum (105 or 106) ; antimonial cholera (175) ; hernial cholera (108). 

14. Dysentery. Include: Choleriform dysentery; Chinese dysentery; dysentery 

of tropical countries. 
14a. Epidemic Dysentery. 

15. Bubonic Plague (Plague or pest). 

16. Yellow Fever. Include: Vomito negro ; amarilla fever ; black vomit. 

17. Leprosy. Include: Elephantiasis Grsecorum. — Do not include: Elephantiasis 

Arabum (i45d) ; Morvan's disease (63); syringomyelitis (63). 

18. Erysipelas. Include: All surgical erysipelas or medical erysipelas, without 

regard to seat ; St. Anthony's fire. — It is disputed whether to classify gan- 
grenous or phlegmonous erysipelas here or under 144. 

19. Other Epidemic Affections. 2 Include: Mumps; rubeola; acrodynia; vari- 

cella ; beriberi ; and any other epidemic affections which may not be in- 
cluded in this nomenclature. — Do not include: Epidemic dysentery (14a) ; 
epidemic cerebrospinal meningitis (61). 

20. Purulent and Septicemic Infection. 3 Include: Pyaemia; purulent ab- 

sorption ; putrid absorption ; putrid infection ; putrid fever ; anatomic 
(dissection) wounds; streptococcaemia. — Do not include: Puerperal septi- 
caemia (137) ; infectious fever (55). 

21. Glanders and Farcy. 

22. Malignant Pustule. Include: Charbon; splenic fever. In France as 143. 

23. Rabies. Include: Hydrophobia. — Do not include: Sitiophobia -(68). 

24. Actinomycosis, Trichinosis, etc. Include: Dystonia hepaticum; cysticerci. 

— Do not include: Cyst or hydatid tumor of the liver (in) or of the lungs 
(99) ; intestinal parasites (107). 

25. Pellagra. 

26. Tuberculosis of the Larynx. Include: Tuberculous laryngitis; laryngeal 

phthisis. 
2j. Tuberculosis of the Lungs.* Include: Pulmonary tuberculosis; pulmonary 
phthisis; phthisis (without qualification) ; phymia; phymatosis ; pneumo- 
phymia ; acute, galloping, or miliary phthisis or tuberculosis ; pulmonary 
cavities ; consumption ; caseous pneumonia ; tuberculous, bacillary, specific, 

1 The word " cholera morbus" will be taken in its ordinary signification in each country, as in the 
sense of " cholera nostras" in North America, and as " Asiatic cholera" in France and in other countries. 

2 In cases where epidemics arise, it will be necessary here to adopt a special provisional title. 

3 When a female of childbearing age is returned as affected with " septicaemia," " sepsis," or any 
similar term, send the report back in order that the physician may state whether or not the disease was 
puerperal. 

4 See observation on No. 93, relative to " apical pneumonia." 



USUAL CAUSES OF DEATH 



493 



granular, neoplastic, or heteroplastic bronchitis or pneumonia; bacillosis; 
tuberculous pleurisy; tuberculous haemoptysis ; tuberculosis (without quali- 
fication). — Do not include: Haemoptysis (without qualification) (99) ; 
pulmonary hemorrhage (99) ; bronchorrhagia (without qualification) (99) ; 
apical pneumonia (93) ; laryngeal phthisis (26) ; pulmonary anthracosis 
(99)- — Frequent complications: Hemorrhage; pneumonia; pleurisy; un- 
controllable diarrhoea. 

28. Tuberculosis of the Meninges. Include: Meningeal tuberculosis; tubercu- 

lous meningitis ; granular, miliary, caseous, bacillary, specific, neoplastic or 
heteroplastic meningitis; tuberculous meningitis of spinal cord. — Do not 
include: Meningitis (without qualification), even for children of tender 
age (61). 

29. Abdominal Tuberculosis. Include: Tuberculous, granular, bacillary, or 

specific peritonitis ; peritoneal tuberculosis ; tuberculous enteritis. 

30. Pott's Disease. Include: Vertebral caries ; vertebral polyarthritis. — Frequent 

complications: Cold abscess, or abscess by congestion; paraplegia. 

31. Cold Abscess (Abscess by Congestion). Include: Ossifluent abscess. 

32. White Swelling. Include: Fungous growths of joints; coxalgia; scapu- 

lalgia ; tuberculosis of joint. 

33. Other Tuberculous Affections. Include: Tuberculosis of the skin, eye, 

bone, genital organs, etc. ; tuberculous adenitis ; lupus ; esthiomene ; bacil- 
lary abscess; tuberculous ulcer. — Do not include: Pott's disease (30). 

34. Generalized Tuberculosis. Include: Tuberculosis showing itself simulta- 

neously in any two or more organs. Often better placed under 27. 

35. Scrofula. (An unsatisfactory title.) Include: Struma; King's evil ; lympha- 

tism ; scrofulides. — Do not include: Scrofulous or lymphatic keratitis and 
blepharitis (75). 

36. Syphilis. Of which are recognized: (1) Primary, (2) secondary, (3) ter- 

tiary, (4) hereditary. These divisions are intended for mortuary statistics 
alone. Include: (1) Indurated or infecting chancre; chancre of the mouth 
or face; primary accident or infection; (2) Secondary manifestations — 
mucous plaques ; syphilitic amygdalitis ; angina or laryngitis ; (3) Tertiary 
manifestations — specific manifestations ; gummata ; ulcerations ; exostoses, 
etc. Osteocopic pains ; all these diseases to be specified as " syphilitic." — 
Do not include: Soft, simple, or phagedenic chancre (36a). 
36a. Soft Chancre. Include: Chancroid; chancrelle; simple chancre ; phagedenic 
chancre or bubo ; bubo of soft chancre ; venereal, virulent, or absorption 
buboes. — Do not include: Infecting or syphilitic chancre or bubo (36, 1) ; 
chancre of the mouth (36, 1) ; scrofulous bubo (35) ; suppurating bubo 
(144); plague bubo (15); bubo (without qualification) (144). (Morbidity 
statistics only.) 

37. Gonorrhoea (five years and over). Include: Blennorrhoea ; ardor urinae; 

urethritis ; military drop ; balanitis ; balanorrhagia ; balanoposthitis, vagi- 
nitis ; gonorrhoeal cystitis, orchitis, buboes, arthritis, rheumatism, or con- 
junctivitis of the adult; or gonorrhoeal or blennorrhagic ophthalmia of the 
adult. — Do not include: Vaginismus (132) ; vaginalitis (126). — Frequent 
complications: Bubo; adenitis; cystitis; orchitis. 

38. Gonorrheal Affections of the Child. 1 Include: Blennorrhagic or gonor- 

rhoeal conjunctivitis of the child; gonorrhoeal vulvitis, etc. 



1 This title takes account only of children under five years of age. 



494 



POST-MORTEM EXAMINATIONS 



39. Cancer and other Malignant Tumors of the Buccal Cavity. Include: 

Cancer of the mouth, lips, tongue, roof of the mouth, velum of palate, maxilla, 
jaw, parotid gland, and tonsil; sarcoma of soft palate; epithelioma, or 
carcinoma, or cancroid of these organs; smoker's cancer. 

40. Cancer and other Malignant Tumors of the Stomach and Liver. 1 In- 

clude: Cancer of the oesophagus; cancer of the cardia; cancer of the py- 
lorus ; carcinoma or scirrhus, or colloid or encephaloid tumor of these 
organs ; gastrocarcinoma ; tumor of the stomach ; scirrhus of liver or 
stomach; hepatic cancer. — Do not include: Hasmatemesis (104). 

41. Cancer and other Malignant Tumors of the Peritoneum, Intestines, and 

Rectum. Include: Cancer, carcinoma, scirrhus, encephaloid, cancroid, or 
epithelioma of the colon and anus ; retroperitoneal sarcoma. 

42. Cancer and other Malignant Tumors of the Female Genital Organs. 

Include: Cancer of the uterus (womb), ovary, vagina, vulva; carcinoma, or 
encephaloid, or colloid tumor, or heteromorphous or neoplastic growth, or 
cancroid, or sarcoma, or epithelioma of these organs. 

43. Cancer and other Malignant Tumors of the Breast. Include: Carcinoma, 

or scirrhus, or encephaloid, or heteromorphous or neoplastic growth, or can- 
croid, or epithelioma of the breast or nipple. 

44. Cancer and other Malignant Tumors of the Skin. Include: Cancroid 

(without qualification) ; epithelioma or epitheliomatous tumor (without 
qualification) ; cancer of the ear, face, nose, or cervicofacial region ; " noli- 
me-tangere;" rodent ulcer. — Do not include: Esthiomene (33); lupus (33). 

45. Cancer and other Malignant Tumors of other Organs, or of Organs not 

specified. Include: Abdominal cancer; pelvic cancer; cancer of the lung, 
of the kidney, of the bladder, and of the prostate ; cancerous goitre ; thyro- 
sarcoma ; sarcohydrocele ; cancer of the bone ; osteosarcoma ; cancerous or 
sarcomatous tumor of the neck; carcinoma, or scirrhus, or encephaloid, or 
cancerous ulcer, or malignant tumor, or sarcoma, or malignant fungus of 
these organs, or of other organs not specified ; chimney sweeps' cancer ; 
Lobstein's cancer ; fungus nematodes ; sarcoma of leg ; lymphosarcoma, etc. 
— Do not include: Cancer of the oesophagus (40) ; cancer of the anus (41) ; 
cancer of the ovary, vagina, or vulva (42). 

46. Other Tumors (Tumors of the Female Genital Organs excepted). Include: 

Tumor (without qualification); abdominal tumor; intestinal tumor; vas- 
cular or erectile tumor; angioma; lymphoma; lymphadenoma ; lymphato- 
cele; adenoma; chondroma; osteoma; myoma; lipoma; wen; grub; 
sebaceous tumor; cystoma. — Do not include: Cancer and its synonyms (39- 
45) ; tumor of the stomach (40) ; stercoraceous tumor (108) ; tumor of the 
uterus (129) ; hydatid tumor (in) ; cyst of the ovary (131) ; aneurismal 
tumor (81) ; varicose tumor (83) ; polyp of the ear (76) ; polyp of the 
nasal or nasopharyngeal fossae (87) ; uterine polyp (129) ; osteoma (146). 

47. Acute Articular Rheumatism. Include: Rheumatic arthritis; rheumatic 

meningitis; abdominal or cerebral rheumatism; rheumatic vertigo; rheu- 
matic endocarditis, pericarditis, pleurisy, peritonitis, etc. — Do not include: 
Organic heart disease of rheumatic origin (79) ; rheumatic iritis (75) ; 
arthritis deformans (48) ; gonorrhoeal rheumatism (37 and 38). 



1 In countries where the words "organic lesion of the stomach" always signify "cancer of the 
stomach" classify these diagnoses under No. 40. In countries where, on the contrary, this is not always 
so, classify them under No. 104. 



USUAL CAUSES OF DEATH 



495 



48. Chronic Rheumatism and Gout. Include: Arthritis deformans; articular 

rheumatism ; Heberden's disease, podagra ; rheumatic gout ; rheumatism 
(unqualified). 

49. Scurvy. Include: Scorbutus; WerlhofFs disease; Barlow's disease. 

50. Diabetes. Include: Diabetes insipidus and mellitus ; Hirschf eld's disease; 

diabetic gangrene and coma; glycosuria. — Frequent complications: Pneu- 
monia ; furunculosis ; gangrene ; cerebral hemorrhage and cerebral soften- 
ing; tuberculosis. 

51. Exophthalmic Goitre. Include: Exophthalmia ; Basedow's, Graves's, Parry's, 

Stokes's disease; exophthalmic cachexia. — Frequent complications: Hyper- 
trophy of the heart ; cachexia. 

52. Addison's Disease. Include: Adrenal disease. — Freq. compile: Cachexia; 

ascites. 

53. Leukaemia. Include: Adenoleukaemia ; leucocythaemia ; Hodgkin's disease; 

pseudoleukemia. — Freq. compile. : Hemorrhage ; ascites ; apoplexy ; cachexia. 

54. Anaemia ; Chlorosis. The cause of the anaemia should always be given. 

Include: Pernicious anaemia. — Do not include: Cerebral anaemia (74b). 

55. Other General Diseases. Include: Auto-intoxication; infectious fever; viru- 

lent disease (without explanation); visceral steatosis; acromegalia; amy- 
loid or generalized fatty degeneration ; adiposis ; obesity ; polysarcia. 

56. Alcoholism, Acute or Chronic Include: Drunkenness; ethylism; alcoholic 

intoxication ; alcoholic delirium ; alcoholic dementia ; delirium tremens ; 
absinthism; absinthaemia ; dipsomania; " mania-a-potu." — Do not include: 
Alcoholic cirrhosis (112) ; general alcoholic paralysis (67) ; atheroma (81) ; 
or any other disease attributable to alcohol; intoxication amblyopia (75). 

57. Saturnism. Include: Saturnine colic; lead colic; painter's colic; lead en- 

cephalopathia ; lead paralysis ; chronic lead poisoning ; all conditions char- 
acterized as " saturnine." 

58. Other Trade or Occupation Intoxications. Include: Mercurial (hydrar- 

gyrism) ; phosphorus, arsenical, or other intoxication, when special mention 
by the physician makes it clear that the intoxication is the result of a trade. 
Failing in this specific declaration, it should be classed in one of the condi- 
tions under 59. — Do not include: Alcoholism (56). 

59. Other Chronic Poisonings. Include: Morphinism; cocainism; chronic er- 

gotism. — Do not include: Amblyopia from intoxication (75). Note the 
remark under 58. 

II. DISEASES OF THE NERVOUS SYSTEM AND OF THE ORGANS 

OF SPECIAL SENSE. 

60. Encephalitis. Include: Cerebral fever; phrenitis ; periencephalitis. 

61. Simple Meningitis. Include: Meningitis (without qualification) ; meningo- 

encephalitis ; pachymeningitis. 
61a. Epidemic Cerebrospinal Meningitis. Do not include: Tuberculous menin- 
gitis (or other synonym) (28); rheumatic meningitis (47). 

62. Progressive Locomotor Ataxia. Include: Duchenne's disease; posterior 

sclerosis; tabes dorsalis; cerebral ataxia; posterior spinal sclerosis; pro- 
gressive ataxia ; progressive spastic ataxia. 

63. Other Diseases of the Spinal Cord. Include: Disease of the cord; sclerosis 

in plaques; symmetrical sclerosis; lateral sclerosis; sclerosis (without 
qualification) ; Charcot's disease ; Morvan's disease ; syringomyelitis ; hem- 
orrhage into the spinal cord; haematomyelitis ; haematorrhachia ; myelitis; 



496 POST-MORTEM EXAMINATIONS 

medullary congestion ; affections of the bulb ; bulbar paralysis ; spinal 
paralysis ; paralysis agitans ; trembling paralysis ; ascending paralysis ; 
essential paralysis of infancy; fatty or amyloid degeneration of the cord; 
Parkinson's disease ; Friedreich's disease ; medullary compression or com- 
pression of the cord; progressive muscular atrophy; fatty degeneration of 
muscle ; atrophic muscular paralysis ; amyotrophia ; amyotrophic paralysis ; 
atrophic paralysis; pseudohypertrophic paralysis, etc. 

64. Cerebral Congestion and Hemorrhage. Include: Apoplexy; cerebral apo- 

plexy; meningeal apoplexy; serous apoplexy; cerebral atheroma; oedema 
of the brain; cerebral effusion; cerebellar hemorrhage; meningeal hemor- 
rhage; cataplexia; apoplectic dementia; stroke (unqualified); clot on 
brain. — Frequent complications: Hemiplegia; paralysis. 

65. Cerebral Softening. Do not include: Senile dementia (154). — Frequent 

complications: Hemiplegia; paralysis; pulmonary congestion. 

66. Paralysis without Specified Cause. Include: Paralysis (without qualifica- 

tion) ; hemiplegia; facial paralysis; generalized paralysis (not insane or 
unqualified) ; palsy. — Do not include: Diphtheritic paralysis (9) ; atrophic 
muscular paralysis (63) ; general paralysis (67) ; paralytic cachexia (maras- 
mus) (67) ; paralytic dementia (idiocy) (67) ; shaking (67) or trembling 
paralysis (63) ; bulbar paralysis (63) ; ascending paralysis (63) ; essential 
paralysis of infancy (63) ; labioglossolaryngeal paralysis (74b) ; paralysis 
of the velum palati (101) ; paralysis of the muscles of the eye (75). 

67. General Paralysis. Include: Paralytic lunacy; paralytic dementia; para- 

lytic cachexia ; paralytic marasmus ; diffuse meningoencephalitis ; diffuse 
peri-encephalitis. — Do not include: Generalized paralysis (not insane) (66). 

68. Other Forms of Mental Alienation. Include: Dementia; lunacy; un- 

soundness of mind; hallucinations; mania; megalomania; monomania; 
delusions of persecution ; melancholia ; lypemania ; nostalgia ; insanity ; 
nosophobia ; necrophobia ; sitiophobia ; lycanthropy ; homesickness ; andro- 
mania ; nymphomania ; priapism ; satyriasis ; mental disease. — Do not in- 
clude: Alcoholic dementia or delirium (56) ; delirium tremens (56) ; de- 
lirium (179) ; ursemic delirium (120) ; apoplectic dementia (64) ; paralytic 
dementia (67) ; choreic dementia (73) ; senile dementia (154) ; hysteria 
(74a). 

69. Epilepsy. Include: " Haut and petit mal ;" disease of Hercules ; fits; falling 

sickness. — Do not include: Epileptiform convulsions (70-71). 

70. Eclampsia (Non-puerperal). 1 Include: Epileptiform convulsions (of adults). 

■ — Do not include: Scarlatinous eclampsia (7) ; ursemic eclampsia (120) ; 
eclampsia of children under five years of age (71). 

71. Convulsions of Children. 2 Include: Eclampsia of young children; con- 

tractures of children; spasms. — Do not include: Trismus nascentium (72). 

72. Tetanus. Include: Opisthotonos; emprosthotonos ; pleurosthotonos ; tris- 

mus nascentium or neonatorum ; lockjaw; idiopathic tetanus. 

72>. Chorea. Include: Choreic dementia; Bergeron's disease; St. Vitus' s dance. 

74. Hysteria. Include: Hysterical anorexia ; hysterical colic ; all diseases classi- 
fied as "hysterical." (Morbidity statistics alone.) 

74a. Neuralgia. Include: Tic douloureux; sciatica. (Morbidity statistics alone.) 

1 When a female of childbearing age is designated as having been stricken with " eclampsia," return 
the report to have the physician state whether or not the disease was puerperal. 

2 This title applies only to children under five years of age. 



USUAL CAUSES OF DEATH 497 

74b. Other Diseases of the Nervous System. Include: Cerebral compression; 
cerebral tumor; acquired hydrocephalus ; neuroma; encephalopathia (with- 
out qualification); idiocy; imbecility; cretinism; gatism; amnesia; param- 
nesia ; loss of speech ; aphasia ; nervous or cerebral accidents ; cerebral 
anaemia; neurosis; tic; convulsive tic; contracture; anaesthesia (not due 
to external anaesthetic) ; neurasthenia; migraine; vertigo; somnambulism; 
catalepsy; boulimia; Landry's disease; symptomatic or Jacksonian epilepsy; 
athetosis ; labioglossolaryngeal paralysis ; amyloid or fatty degeneration of 
the nervous system, etc. — Do not include: Senile dementia, imbecility or 
senile gatism (154) ; syringomyelitis (63) ; myxcedema (89) ; congenital or 
undescribed hydrocephalus (150). 

75. Diseases of the Eye and its Adnexa. Include: Ophthalmia; foreign bodies ; 

conjunctivitis (not including diphtheritic or gonorrheal conjunctivitis) ; 
xerosis ; pterygion ; Pinguecula ; keratitis of every variety ; staphy- 
loma ; diseases of the cornea ; arcus senilis ; diseases of the sclerotic ; dis- 
eases of the iris ; iritis ; diseases of the choroid ; choroiditis ; iridocho- 
roiditis ; sclerochoroiditis ; glaucoma ; diseases of the retina ; retinitis ; 
optic neuritis ; amaurosis ; amblyopia ; amblyopia from intoxication ; hemi- 
opia ; hemeralopia ; nyctalopia ; diseases of the lens ; cataract ; aphacia ; 
parasites of the eye ; ophthalmozoa ; coloboma ; strabismus ; strabotomy ; 
paralysis of the muscles of the eye; nystagmus; styes; chalazion; blepha- 
ritis ; blepharoconjunctivitis ; scrofulous blepharitis ; blepharophimosis ; bleph- 
aroplastia ; ectropion ; entropion ; trichiasis ; dacryoadenitis ; diseases of 
the lachrymal gland and lachrymal sac ; dacryocystitis ; dacryolithiasis ; 
dacryoma; lachrymal fistula; diseases and tumors of the orbit (undefined). 
— Do not include: Diphtheritic (9) or gonorrhoeal (37-38) conjunctivitis; 
ocular cancer (45) or tuberculosis (33) ; exophthalmic goitre (51) ; ex- 
ophthalmia (51). Many titles in 75 are never employed as causes of death. 

75a. Follicular Conjunctivitis. (Morbidity statistics alone.) 

75b. Trachoma. (Morbidity statistics alone.) 

76. Diseases of the Ear. Include: Otitis; otorrhcea; catarrh of the ear ; hydro- 

titis ; foreign body in the auditory canal ; obstruction of the auditory canal ; 
polyp of the ear ; inflammation of the tympanum ; " vertigo ab aure laeso ;" 
Meniere's disease, or vertigo; caries of the labyrinth (?) ; deafness; deaf- 
mutism. — Do not include: Mumps (19). 

III. DISEASES OF THE CIRCULATORY APPARATUS. 

77. Pericarditis. Include: Cardiopericarditis ; hydropericarditis ; hydropneumo- 

pericarditis ; pericardial adhesions. — Do not include: Rheumatic pericarditis 
(47) ; endopericarditis (78) ; pleuropericarditis (94) ; pneumopericarditis 

(93). 

78. Acute Endocarditis. Include: Endocarditis (without qualification) ; myo- 

carditis, acute or without qualification; endopericarditis. — Do not include; 
Rheumatic endocarditis (47), or the other cardiac accidents which may 
supervene in the course of an attack of rheumatism. 

79. Organic Diseases of the Heart. Include: Aortic, mitral, tricuspid, or car- 

diac affection or lesion; cardiac or valvular insufficiency or stenosis of the 
valves of the heart; cardiac cachexia; hypertrophy of the heart; dilatation 
of the heart ; cardiectasis ; steatosis of the heart ; degeneration of the heart ; 
cardiopathy; cardiosclerosis; cardiovascular sclerosis; cardiomalacia ; car- 
diostenosis; labored heart; tachycardia; rupture of the heart; cardior- 

32 



49 8 POST-MORTEM EXAMINATIONS 

rhexia; cardiac palpitation; asystole; cardiac asthma. — Do not include: 
Cardiac accidents (undetermined) (86) ; persistence or patency of the fora- 
men of Botallo (150). — Frequent complications: Dropsy; bronchitis and 
pneumonia ; albuminuria ; embolism ; thrombosis. 

80. Angina Pectoris. Include: Cardialgia; sternalgia; neuralgia of the heart. 

81. Affections of the Arteries, Atheroma, Aneurism, etc. Include: Arteritis; 

fatty degeneration of arteries ; arteriosclerosis ; atheroma of arteries ; arte- 
riectasis ; aortic ectasis ; Hodgson's disease ; atresia of the pulmonary ar- 
tery; aortitis; aneurismal tumor. — Do not include: Aortic affection (79). 

82. Embolism and Thrombosis. Include: Thrombosis (without qualification) ; 

phlegmasia alba dolens (non-puerperal) ; embolic pneumonia. — Do not in- 
clude: Embolism (puerperal) (140). 

83. Affections of the Veins (Varices, Hemorrhoids, Phlebitis, etc.). Include: 

Pneumophlebitis ; varicose ulcer; varicocele. — Do not include: Puerperal 
phlebitis (137) ; vascular or erectile tumor (46) ; angioma (46). 

84. Affections of the Lymphatic System. Include: Angioleucitis ; adenopa- 

thia; lymphangeitis ; adenitis. — Do not include: Suppurative adenitis (144) ; 
adenophlegmon (144) ; leukemic adenitis (53) ; lymphatism (35) ; bubo 
(36a and 144) ; adenoma (46) ; lymphoma (46) ; lymphadenoma (46). 

85. Hemorrhages. Include: Hemorrhage (without qualification) ; internal hem- 

orrhage ; haemophilia ; epistaxis ; stomatorrhagia ; cutaneous hemorrhage ; 
purpura hemorrhagica. — Do not include: Cerebral hemorrhage (64) ; cere- 
bellar hemorrhage (64) ; meningeal hemorrhage (64) ; pulmonary hemor- 
rhage (99) ; haemoptysis (99) ; haematemesis (104) ; intestinal hemorrhage 
(109) ; hsematuria (121) ; uterine hemorrhage (135 or 128, depending on 
whether it is or is not puerperal) ; metrorrhagia (128 or 135) ; umbilical 
hemorrhage (under three months) (152) ; traumatic hemorrhage (166). 

86. Other Affections of the Circulatory Apparatus. Include: Cardiac acci- 

dents (undetermined); angiectasis; angiectopia ; affections of the great 
vessels; permanently slow pulse. — Do not include: Vascular naevus (150). 

IV. DISEASES OF THE RESPIRATORY APPARATUS. 

87. Diseases of the Nasal Fossae. Include: Coryza; cold; polypus of the nasal 

or nasopharyngeal fossa ; ozaena ; abscess of the nasal fossa ; adenoid vege- 
tations. — Do not include: Epistaxis (85) ; syphilitic coryza (36). 

88. Affections of the Larynx. Include: Acute, chronic, erysipelatous, oedema- 

tous, phlegmonous, or stridulous laryngitis ; aphonia ; loss of voice ; false 
croup ; spasmodic croup ; stridulous croup ; cedema of the glottis ; spasm of 
the glottis ; polypus of the larynx ; stricture of the larynx ; laryngotomy. — 
Do not include: Tuberculous laryngitis (26) ; laryngeal tuberculosis (26) ; 
croup (9) ; diphtheritic laryngitis and its synonyms (9) ; foreign bodies in 
the larynx (176). 

89. Affections of the Thyroid Body. Include: Goitre; thyrocele; myxoe- 

dema ; pachydermic cachexia. — Do not include: Exophthalmic goitre (51). 

90. Bronchitis, Acute. 1 Include: Capillary bronchitis; tracheitis; tracheobron- 

chitis; broncho-alveolitis. — Do not include: Bronchopneumonia (92); spe- 
cific bronchitis or other synonym of pulmonary tuberculosis (see 27) ; 
fetid bronchitis (96) ; summer bronchitis (99). 



See note on No. 91. 



USUAL CAUSES OF DEATH 



499 



91. Bronchitis. Chronic. 1 Include: Mucous bronchitis (pituitous) ; catarrh 

(without qualification) ; bronchial, pituitous, pulmonary, or suffocating 
catarrh ; bronchorrhcea ; dilatation of the bronchi ; bronchiectasis. — Do not 
include: Fetid bronchitis (96) ; tuberculous bronchitis (27). 

92. Bronchopneumonia. Include: Catarrhal, deglutition, and aspiration pneu- 

monia. — Do not include: Capillary bronchitis (90). 

93. Pneumonia. 2 Include: Croupous pneumonia; fluxion of the lung; pleuro- 

pneumonia ; pneumopleurisy : splenopneumonia ; apical pneumonia ; peri- 
pneumonia ; pneumopericarditis ; typhoid and alcoholic pneumonia. — Do not 
include: Caseous pneumonia (27) ; specific, bacillary, or any synonym of 
pulmonary tuberculosis (27) ; pulmonary congestion (95). 

94. Pleurisy. Include: Pleuropericarditis ; pleuritic or thoracic effusion; pneu- 

mothorax ; hydropneumothorax ; pyothorax ; pleural vomica ; pneumopyo- 
thorax ; hemothorax ; thoracentesis ; empyema ; pleural adhesions. — Do 
not include: Pleurodynia (99). 

95. Pulmonary Congestion and Pulmonary Apoplexy. Include: (Edema of the 

lungs ; hypostatic pneumonia. 

96. Gangrene of the Lung. Include : Fetid bronchitis ; mortification of lung. 

97. Asthma. Do not include: Cardiac asthma (79) ; suffocating catarrh (91) ; 

hay fever (99). 

98. Emphysema of the Lungs. Include: Emphysema (without qualification). — 

Do not include: Subcutaneous emphysema (145). 

99. Other Diseases of the Respiratory Apparatus (Phthisis excepted). In- 

clude: Tracheostenosis; pleurodynia; pneumopathy; hydatids of the lung ; 
pulmonary calculus ; abscess of the lung ; pulmonary anthracosis ; inter- 
stitial pneumonia ; cirrhosis of the lung ; secondary sclerosis ; hay fever 
(summer bronchitis or catarrh). To be also included when their nature is 
not indicated : Organic lesion of the lung ; pulmonary accidents ; haemop- 
tysis; spitting of blood; pulmonary hemorrhage; pneumorrhagia ; bron- 
chorrhagia; tracheotomy. — Do not include: Cancer of the lung (45). 

V. DISEASES OF THE DIGESTIVE APPARATUS. 

100. Affections of the Mouth and its Adnexa. Include: Diseases of the gums ; 

epulis; gingivitis; ulorrhagia ; glossitis; diseases of the tongue (except 
cancer); parotid tumor; parotiditis; salivary fistula; ranula ; thrush; 
diseases of the teeth; odontalgia; dental caries; staphylitis ; staphylo- 
plasty; staphylorrhaphy. — Do not include: Cancer of the lips or tongue 
(39); chancre of the mouth (36a); noma (142); mumps (19); gangrene 
of the mouth (142) ,- diseases of the palate (36 or 146) ; fracture of the 
maxilla (164); necrosis of the maxilla (146); paralysis of the velum 
palati (101). 

101. Affections of the Pharynx. Include: Angina or Ludwig's disease; anginas 

of all varieties (except diphtheritic angina and its symptoms; see Diph- 
theria. No. 9): amygdalitis; quinsy; abscess of the fauces, throat, or 



i Return to the physician the reports given in as " bronchitis," in order that he may specify acute or 
chronic. When the physician fails thus to answer, classify under No. 90 all reports relating to children 
under five years of age, and under No. 91 all reports as to those of greater age. 

2 In countries where " apical pneumonia " is always synonymous with " phthisis," class this diagnosis 
under No. 27. In countries, on the contrary, where this is not constant, class under No. 93. 



r 



5oo 



POST-MORTEM EXAMINATIONS 






retropharynx ; paralysis of the velum palati ; elongation of the uvula ; 
pharyngitis; tonsillitis. — Do not include: Angina pectoris (80); cardiac 
angina (80) ; scarlatinal angina (7). 

102. Affections of the GEsophagus. Include: Foreign bodies in the oesophagus; 

wound of the oesophagus; stricture of the oesophagus (except from can- 
cer); spasm of the oesophagus; cesophagotomy. — Do not include: Cancer 
of the oesophagus (40) ; syphilitic stricture of the oesophagus (36). 

103. Ulcer of the Stomach. Include: Round ulcer. — Frequent complications: 

Haematemesis ; perforations of the stomach ; peritonitis. 

104. Other Affections of the Stomach (Cancer excepted). 1 Include: Dilata- 

tion of the stomach; paresis of the stomach; dyspepsia; apepsia; gas- 
tritis; gastrohepatitis ; foreign body in the stomach; gastrotomy; perfora- 
tion of the stomach (non-traumatic); gastralgia; "vertigo a stomacho 
lseso ;" catarrh of the stomach; indigestion. To be also included when 
their nature is not indicated : Gastrorrhagia ; haematemesis ; gastric hemor- 
rhage. — Do not include: Gastro-enteritis (105 or 106, according to age). 

105. Diarrhcea and Enteritis (under two years). Include: Gastro-enteritis or 

gastrocolitis of children; infantile enteritis; cholera infantum; athrepsia. 
This title only considers these ailments in children under two years. 
105a. Diarrhcea and Enteritis, Chronic (under two years). Include: Athrepsia. 

106. Diarrhcea and Enteritis (two years and over). Include: Gastro-enteritis 

or gastrocolitis of adults ; enteritis of adults ; diarrhcea of adults ; lieno- 
enteritis ; intestinal ulcerations ; colitis ; intestinal colic ; flatulent colic ; 
inflammatory colic. Do not include: Tuberculous enteritis (29). 

107. Intestinal Parasites. Include: Helminthae; oxyuri; taeniae* of all kinds; 

solitary worm; ascaris lumbricoides ; trematodes; trichocephalus ; anchy- 
lostomes ; colic from worms. 

108. Hernias and Intestinal Obstructions. Include: Internal strangulation; 

intestinal invagination ; stercoral tumors ; ileus ; intestinal occlusion ; volvu- 
lus ; hernial colic ; hernial gangrene. The following to be included when 
their nature is not specified : Merocele ; sarco-epiplocele ; sarco-epiplom- 
phalitis; kelotomy; herniotomy; artificial anus; stercoraceous vomiting. 
— Do not include: Laparotomy (without other qualification) (46 and 179). 
— Frequent complication: Peritonitis. 

109. Other Affections of the Intestines. Include: Paralysis or paresis of the 

intestine ; enteroptosis ; constipation ; stercorsemia ; intestinal calculi ; in- 
testinal perforation ; foreign bodies in the intestine or rectum ; rectitis. 
Include also the following diseases when their nature is not indicated, and 
these operations when their cause is not specified : Enterotomy ; artificial 
anus; enterrhagia; intestinal hemorrhage; melaena; prolapse of the rec- 
tum; stricture of the rectum. — Do not include: Stercoral tumor (108); 
intestinal invagination and its synonyms (108) ; typhlitis and appendicitis 
(118); perityphlitis (118). 
109a. Diseases of the Anus and Fecal Fistulas. Include: Proctitis; periproc- 
titis ; proctocele ; proctoptosis ; fissure of the anus ; abscess of the margin 
of the anus ; fistula of the anus, either fecal or rectovaginal. — Do not in- 
clude: Urinary fistulae, even when these involve the rectum (124) ; artifi- 
cial anus (108) (morbidity statistics alone); unnatural anus (108); im- 
perforate anus (150). (For morbidity statistics alone.) 

1 See observation under No. 40 as to " organic lesion of the stomach.'" 



L 



USUAL CAUSES OF DEATH 



50I 



no. Acute Yellow Atrophy of the Liver. Include: Pernicious icterus; paren- 
chymatous hepatitis; Weil's disease. — Do not include: Icterus (without 
qualification) (114) ; chronic icterus (114) ; icterus of the new-born (uncLr 
three months) (151). 

in. Hydatid Tumors of the Liver. Include: Hydatid cyst; hydatids (without 
qualification) ; echinococci. 

112. Cirrhosis of the Liver. Include: Cirrhosis (without qualification) ; alco- 

holic cirrhosis ; interstitial cirrhosis ; biliary cirrhosis : amyloid or fatty 
degeneration of the liver; slow atrophy of the liver: steatosis of the liver; 
alcoholic, interstitial, or chronic hepatitis. — Do not include: Organic lesion 
of the liver (114) ; hypertrophy of the liver (114). — Frequent complica- 
tions: Dropsy; hemorrhage; pneumonia; tuberculosis. 

113. Biliary Calculi. Include: Hepatic calculi; biliary lithiasis ; hepatic colic. 

114. Other Affections of the Liver. Include: Abscess of the liver; hepatitis; 

hepatitis, acute ; angiocholitis ; cholecystitis ; hepatocystitis ; choluria. To 
be also included when their precise nature is not indicated : Organic lesion 
of the liver; tumor of the liver; hypertrophy of the liver; acholia; cho- 
laemia; icterus (over three months); chronic icterus; jaundice; hepatic 
congestion. — Do not include: Acute yellow atrophy of the liver (no) ; 
icterus of the new-born (151). 

115. Affections of the Spleen. Include: Splenitis; splenopathia ; megalosple- 

nia; splenocele. — Do not include: The affections of the spleen due to 
leukaemia (53) or malaria (4). 

116. Peritonitis, Simple (Puerperal excepted). 1 Include: Peritonitis (without 

qualification); peritonitis, chronic; peritoneal adhesions; epiploitis ; metro- 
peritonitis, pelviperitonitis. — Do not include: Tuberculous peritonitis (29) ; 
cancer of the peritoneum (41) ; puerperal peritonitis (137) ; rheumatic 
peritonitis (47). 

117. Other Affections of the Digestive Apparatus (Cancer and Tuberculosis ex- 

cepted). Include: Diseases of the pancreas (cancer excepted). 

118. Appendicitis and Abscess of the Iliac Fossa. Include: Iliac phlegmon 

or abscess ; typhlitis ; perityphlitis ; typhlodicliditis ; appendicitis. — Do not 
include: Pelvic (130) or periuterine abscess; pelvic suppuration (130). 

VI. DISEASES OF THE GENITO-URINARY APPARATUS AND ITS 
ADNEXA (NOT INCLUDING VENEREAL DISEASES). 

119. Nephritis, Acute. Do not include: Scarlatinous nephritis (7) ; chronic 

nephritis (120); tuberculous nephritis (33); nephritis of pregnancy (138). 

120. Bright's Disease. Include: Chronic, albuminous, interstitial, or parenchy- 

matous nephritis ; albuminuria ; amyloid or fatty degeneration of the kid- 
ney; amyloid kidney; steatosis of the kidney; renal sclerosis. To be in- 
cluded when their precise nature is not indicated : Uraemia ; uraemic 
eclampsia; uraemic delirium; uraemic coma. — Do not include: Organic 
lesion of the kidney (121) ; puerperal uraemia (138) ; cardiac albuminuria 
(79). — Frequent complications: Anasarca; dropsy; convulsions; hemor- 
rhages ; cerebral apoplexy : pneumonia. 

1 When a female of childbearing age is returned as having been stricken with "peritonitis," with 
out other explanation, the report should be returned in order that the physician may specify whether or 
not the condition was puerperal. 



502 



POST-MORTEM EXAMINATIONS 



121. Other Diseases of the Kidneys and their Adnexa. Include: Pyelitis; 

anuria ; renal congestion ; renal ectopia ; nephroptosis ; floating, motile, or 
displaced kidney ; movable kidney ; renal cysts ; polycystic kidney ; hydro- 
nephrosis ; hsematuria ; perinephritis ; perinephritic and nephritic abscess ; 
pyelonephritis ; nephropyosis. To be also included when their nature is 
not specified : Organic lesion of the kidney ; nephrorrhagia. 

122. Calculi of the Urinary Tract. Include: Renal, ureteral, nephritic, vesical, 

or urinary calculus; nephritic colic; nephrolithiasis; gravel; stone; cal- 
culous affections; urinary lithiasis; lithotrity; lithoclasty. — Do not in- 
clude: Prostatic calculus (125). 

123. Diseases of the Bladder. Include: Cystitis, acute or chronic vesical or 

ureteral catarrh ; cystorrhagia ; tumor of the bladder ; cystocele ; cystop- 
tosis; foreign body in the bladder; cystotomy; retention of urine; 
dysuria ; paralysis and section of bladder; vesical inertia; incontinence 
of urine; tenesmus of the bladder. — Do not include: Hsematuria (121); 
urinary fistulse, even when they involve the bladder (124) ; cystosarcoma 

(45). 

124. Diseases of the Urethra. Include: Urinary abscess, etc.; ankylurethria ; 

foreign bodies; urethrotomy; urinary fistula (urethral, urethrorectal, vesi- 
corectal, or vesicometrorectal) ; urinary infiltration ; urinary intoxication ; 
urethralgia ; urethrorrhagia ; urinaemia ; stricture of the urethra ; urethro- 
stenosis ; urethroplasty; urethrorrhaphy ; stricture (male). — Do not in- 
clude: Ureteral catarrh (123) ; retention of urine (123). 

125. Diseases of the Prostate. Include: Hypertrophy of the prostate; prosta- 

titis; abscess of the prostate; prostatic calculus. — Do not include: Cancer 
of the prostate (45) ; tuberculosis of the prostate (33). 

126. Non-venereal Diseases of the Genital Organs of the Male. Include: 

Phimosis; paraphimosis; amputation of the penis; seminal losses; sper- 
matorrhoea; orchitis; epididymitis; funiculitis; hydrocele; haematocele 
of the testicle, cord, or scrotum; castration (in man) ; Malassez's disease. 
— Do not include: Cancer of the testicle (45) ; tuberculosis of the testicle 
(33) \ sarcohydrocele (45) ; syphilitic sarcocele (36) ; varicocele (83). 

127. Metritis (non-puerperal or unqualified). Include: Ulcer of the uterus; 

ulceration of the neck (of the womb) ; endometritis. 

128. Uterine Hemorrhage, Non-puerperal. Include: Metrorrhagia; menorrha- 

gia; tamponage of the vagina or uterus. 

129. Uterine Tumor (not cancerous). Include: Fibroid tumor, or fibroid of 

body of the uterus; hysteromyoma ; uterine polypus; fungous or fungoid 
tumors of the uterus ; Huguier's disease. 

130. Other Diseases of the Uterus. Include: Procidentia of uterus; uterine 

or vaginal catarrh; deviation, anteflexion, retroflexion, anteversion, falling 
or prolapse of the uterus; prolapse of the vagina; uterine prolongation; 
amenorrhoea; hypertrophy of the neck of the uterus'; dysmenorrhoea ; 
organic lesion of the uterus ; hysterectomy ; hysterotomy ; metrotomy ; 
ablation of the uterus; abscess of the pelvis; periuterine or retro-uterine 
abscess or phlegmon ; pelvic suppuration ; leucorrhcea ; fluor albus 
(whites; vaginal flow; white flux). — Do not include: Puerperal diseases 
(134 and 141) ; abscess of the iliac fossa (118). 

131. Cysts and other Tumors of the Ovary. Include: Ovariotomy; castration 

(in the female). Dermoid cyst often classified better here than under 
146. 



USUAL CAUSES OF DEATH 



503 



132. Other Diseases of the Genital Organs of the Female. Include: Vaginis- 
mus ; tumors of the vagina ; ovaritis ; salpingitis ; salpinx ; metrosalpin- 
gitis ; haematosalpinx ; pyosalpinx ; abscess and tumors of the vulvovaginal 
glands; vulvitis; periuterine or retro-uterine hematocele. — Do not include: 
Urinary fistulae (124) ; stercoral fistulse (109a) ; even when they involve 
the genital organs. King makes a subheading of " Diseases of tubes." 

133- Non-puerperal Diseases of the Breast (Cancer excepted). Include: Mam- 
mitis; abscess of the breast (non-puerperal); cyst of the breast; cystic 
disease of Reclus; tumor of the breast (without qualification, or non- 
cancerous) ; amputation of the breast. — Do not include: Fistula of the 
breast (puerperal, or without qualification) (43) ; mammary cancer (43). 

VII. THE PUERPERAL STATE. 

Remarks. — It often happens that physicians neglect to note the puerperal char- 
acter of the disease ; hence the following rule for the guidance of those whose duty 
it is to collect statistics. " Whenever a female of childbearing age is noted as 
dead from a disease which may be puerperal, the report should be returned to the 
reporter, in order that he may state explicitly whether or not the disease was puer- 
peral." The following are these diseases : Peritonitis ; pelviperitonitis ; metroperi- 
tonitis ; septicaemia ; hemorrhage ; metrorrhagia ; eclampsia ; phlegmasia alba dolens ; 
phlebitis ; lymphangeitis ; embolism ; sudden death ; abscess of the breast. 

134. Accidents of Pregnancy. Include: Miscarriage (death of mother) ; abor- 

tion (death of mother); hemorrhage of pregnancy; incoercible vomiting; 
rupture of tubal pregnancy ; ablation of the pregnant tube ; difficulties and 
fatigues supervening in the course of pregnancy. 
134a. Labor, Normal. (Morbidity statistics only.) 

135. Puerperal Hemorrhage. Include: Puerperal metrorrhagia; post-partum 

hemorrhage. 

136. Other Accidents of Labor. Include: Dystocia; Cesarean section; rupture 

of the uterus ; metrorrhexia ; laceration or rupture of the perineum ; peri- 
neorrhaphy; placenta previa; malposition, retention, detachment, or apo- 
plexy of the placenta; cephalotripsy ; embryotomy (adult); symphyseot- 
omy ; version ; application of forceps ; uterine inversion. 

137. Puerperal Septicemia. Include: Puerperal fever; puerperal infection; puer- 

peral endometritis ; puerperal salpingitis ; perimetrosalpingitis, or phlegmon 
of the broad ligament, or diffuse pelvic puerperal cellulitis ; puerperal peri- 
tonitis, metroperitonitis, phlebitis, lymphangeitis, or pyemia. — Do not in- 
clude: Septicemia (without qualification) (20). 

138. Puerperal Albuminuria and Eclampsia. Include: Puerperal uremia; ne- 

phritis of pregnancy; eclampsia of women in labor; epileptiform convul- 
sions of women in labor ; puerperal tetanus. 

139. Phlegmasia Alba Dolens, Puerperal. Do not include: Phlegmasia alba 

dolens, non-puerperal (82). — Frequent complications: Gangrene; embolism. 

140. Other Puerperal Accidents; Sudden Death. Include: Puerperal embo- 

lism ; puerperal thrombus ; sudden death in the puerperium ; consequence 
of labor (without other explanation) ; subinvolution of uterus. — Do not 
include: Sudden death, non-puerperal (178) ; puerperal scarlatina (7). 

141. Puerperal Diseases of the Breast. Include: Fissure of the nipple (puer- 

peral) ; circumscribed abscess; abscess of the breast (puerperal); fistula 
of the breast (puerperal or without further indication). 



504 



POST-MORTEM EXAMINATIONS 
VIII. DISEASES OF THE SKIN AND CELLULAR TISSUE. 



142. Gangrene. Include: Eschar; sphacelus; gangrene, dry; gangrene, senile; 

gangrene of the extremities ; gangrene of the mouth ; gangrene of the 
vulva, etc.; noma; Raynaud's disease. — Do not include: Gangrene of the 
lung (96) ; hernial gangrene (108) ; gangrenous erysipelas (18 or 144). 

143. Furuncle (Carbuncle). 1 Not included: Biskra, Aleppo, or Medina button (145). 

144. Phlegmon; Warm Abscess. Include: Abscess (without qualification); 

phlegmonous tumor ; adenophlegmon; suppurative adenitis ; bubo (with- 
out qualification); suppurating bubo; diffuse phlegmon; phlegmonous or 
gangrenous erysipelas ; panaris ; whitlow ; abscess of the mediastinum ; 
vomica (without any modification). — Do not include: Bacillary abscess 
(33) ', abscess of the fauces, throat, or retropharynx (101) ; of the liver 
(114); of the iliac fossa (118) ; of the female pelvis (130) ; of the pros- 
tate (125) ; urinary (124) ; periuterine (130) ; of breast, non-puerperal 
(130) ; cold (31) ; by congestion (31) ; ossifluent (31) ; angioleucitis (84). 

145. Tinea Favus. (Morbidity statistics alone.) 

145a. Tinea Tonsurans, Trichophyton. Include: Tinea (without qualification). 
(Morbidity statistics alone.) 

145b. Pelades. (Morbidity statistics alone.) 

145c. Itch. (Morbidity statistics alone.) 

I45d. Other Diseases of the Skin and its Adnexa. Include: Erythema; urti- 
caria ; prurigo, pityriasis ; lichen ; psoriasis ; dermatitis ; eczema ; im- 
petigo ; aphtha ; herpes ; ecthyma ; elephantiasis Arabum ; pachyderma- 
titis; polysarcia; scleroderma; keloids; fungoid mycosis; seborrhcea; 
trophoneuroses; zona; Wardrop's disease; Biskra, Aleppo, or Medina 
button; Pendjeh ulcer; Cochin-China ulcer; pemphigus; myiasis. — Do 
not include: Pachydermatous cachexia (89) ; elephantiasis Grsecorum (17). 

IX. DISEASES OF THE ORGANS OF LOCOMOTION. 

146. Affections of the Bones (Non-tuberculous). Include: Periostitis; perios- 

tosis ; osteitis ; osteoperiostitis ; osteomyelitis ; caries ; necrosis ; seques- 
trum ; perforation of the palatine vault; necrosis of the maxilla (non- 
phosphoric or without qualification) ; exostosis (without qualification) ; 
osteoma ; osseous tumor ; cranial tumor ; foreign bodies in the frontal or 
other sinuses ; mastoiditis ; abscess of the frontal or maxillary sinus ; 
osteomalacia; softening of bone ; rhachitis ; scoliosis; lordosis; kyphosis. — 
Do not include: Caries of the petrous bone (76) ; dental caries (100) ; 
osteocopic pains (36) ; osteosarcoma (45) ; phosphorus necrosis (58). 

147. Arthritis and other Diseases of the Joints (Tuberculosis and Rheumatism 

excepted). Include: Arthritis; polyarthritis ( non- vertebral ) ; hydrarthro- 
sis; foreign bodies in joints; arthrodynia; arthropyosis ; arthrophytis ; 
ankylosis; arthralgia; arthrocele ; genu valgum. — Do not include: Rheu- 
matic arthritis (47). 

148. Amputation. 2 Include: Only those cases in which the lesion, the cause for 

amputation, is not specified. — Do not include: Amputation of the breast 



1 See No 22. 

3 Amputation, surgical operation, shock, and surgical shock, unqualified, are not sufficiently specific 
terms as causes of death. 



USUAL CAUSES OF DEATH 



505 



(133) 5 amputation of the penis (126). — Frequent complications: Septi- 
caemia ; erysipelas ; tetanus ; hemorrhage. 

149. Other Affections of the Organs of Locomotion. Include: Hygroma; peri- 

chondritis ; disarticulation ; tarsalgia ; painful talipes valgus ; retraction 
of the fingers or of the palmar aponeurosis ; Dupuytren's disease ; non- 
traumatic muscular rupture; muscular diastasis; myodiastasis ; non-trau- 
matic rupture of a tendon ; diseases of tendons ; tenophytes ; tenosynovitis ; 
tenotomy; tenorrhaphy; torticollis; lumbago; curvature. 

X. MALFORMATIONS. 

150. Malformations (Stillbirths not included). Include: Malformation; mon- 

strosity ; anomaly ; arrest of development ; congenital hydrocephalus ; hydro- 
cephalus (without qualification) ; megalocephalus ; hydrorrhachia ; spina 
bifida ; encephalocele ; podencephalia ; congenital eventration ; omphalo- 
cele ; exomphalos ; ectopia ; imperforate anus, etc. ; harelip ; cleft palate ; 
anaspadias ; hypospadias ; cryptorchid ; vascular naevus ; polydactylia ; syn- 
dactylia ; congenital club-foot ; talipes valgus, varus, or equinus, congenital ; 
congenital deafness or blindness ; persistence of the foramen of Botallo 
(foramen ovale). — Do not include: Coloboma (75) ; painful flat-foot 
(149) ; acquired hydrocephalus (74b) ; tuberculous hydrocephalus (28). 
King makes a separate subheading for hydrocephalus and cyanosis. 

XL EARLY INFANCY. 

150a. The New-born and Nurslings departing from Hospitals without having 
been Sick. (Morbidity statistics alone.) 

151. Congenital Debility, Icterus, and Sclerema. Include: Premature birth 

(not stillborn) ; atrophy (infantile) ; icterus or hepatitis of the new-born; 
atelectasis of the lungs in the new-born ; oedema of the new-born. 

152. Other Diseases of Early Infancy. Include: Umbilical hemorrhage; in- 

flammation of the umbilicus; cyanosis of the new-born. (This title has 
reference to children not more than three months old.) 

153. Lack of Care. 

XII. OLD AGE. 

154. Senile Debility. Include: Senility; old age; cachexia (of the old) ; senile 

exhaustion; senile dementia.— Do not include: Senile gangrene (142). 

XIII. AFFECTIONS PRODUCED BY EXTERNAL CAUSES. 

Among suicides there should only be classed those in whom suicide or attempted 
suicide is clearly demonstrated. In collective suicides there should only be counted 
those who have attained their majority. Minors ought to be regarded as the victims 
of assassination and placed under 176. 

155. Suicide by Poison. Include: Voluntary poisoning; voluntary absorption of 

sulphuric acid (or any other corrosive substance). — Do not include: Co- 
cainism (59) ; morphinism (59). 

156. Suicide by Asphyxia. Include: Suicide by the vapor of charcoal. 

157. Suicide by Hanging or Strangulation. Include: Legal executions. 

158. Suicide by Drowning. 



506 



POST-MORTEM EXAMINATIONS 



159 



Suicide by Firearms. 



160. Suicide by Cutting Instruments. 

161. Suicide by Jumping from High Places. 

162. Suicide by Crushing. 

163. Other Suicides. 

164. Fractures. Include: Separation of the epiphyses; fracture of the cranium. 

165. Sprains. Include: Strains; ligament-stretching. (Morbidity statistics only.) 
165a. Luxations. Include: Subluxations; dislocations. 

166. Other Accidental Traumatisms. Include: Stabs; contusion; bites (non- 

venomous, non-virulent) ; crushing; railroad accidents (suicide excepted) ; 
wounds by cutting instruments (suicide not demonstrated) ; accidental 
falls; concussion of the brain; perforation of the cranium; traumatic 
hemorrhage; traumatic fever; traumatic eventration; perforation of the 
abdomen or chest ; all acute affections designated as " traumatic ;" wounds 
by firearms. King subdivides into: accidental gunshot wounds; injuries 
by machinery; injuries in mines and quarries; railroad accidents and in- 
juries; injuries by horses and vehicles ; and other accidental traumatisms. 

167. Burns and Scalds. Include: Burns and scalds from steam, petroleum, gaso- 

line, boiling liquid, etc. — Do not include: Conflagration (174). 

168. Burns from Corrosive Substances. Include: Burns by vitriol. 

169. Insolation. Include: Sunstroke. 

170. Freezing. Do not include: Effects of cold (new-born) (153). 

171. Electric Shock. Include: Death from lightning. 

172. Accidental Submersion. Include: Drowning (non-suicidal). 

173. Prostration. Include: Fatigue. (Morbidity statistics alone.) 

173a. Inanition. Include: Hunger; insufficient food (new-born excepted) ; mis- 
ery. — Do not include: Lack of care (new-born) (153) ; lack of nutrition 
(new-born) (153); sitiophobia (68); hysterical anorexia (74a). 

174. Absorption of Deleterious Gases (Suicide excepted). Include: Asphyxia, 

accidental (pathologic asphyxia and suicidal asphyxia excepted) ; as- 
phyxia by illuminating gas ; asphyxia by stoves (fixed or portable) ; 
absorption of carbonic oxid; conflagration; absorption of ammonium sul- 
phid; asphyxia by night-soil; absorption of chloroform; absorption of 
nitrous oxid. — Do not include: Asphyxia of the adult (without qualifica- 
tion) (179) ; asphyxia (under three months) (152). 

175. Other Acute Poisonings. Include: Every acute poisoning (suicide ex- 

cepted) ; antimony cholera; acute ergotism; absorption of venom; bite 
of serpent; accidental absorption of sulphuric acid or other corrosive sub- 
stances. — Do not include: Saturnism (57); hydrargyrism, etc. (58 or 59), 
morphinism, chronic ergotism, etc. (59). 

176. Other External Violence. Include: Accident (without other qualifica- 

tion) ; bad treatment (of a child); capital punishment; foreign body in 
the larynx ; foreign body in the trachea. King subdivides into : Suffoca- 
tion ; injuries at birth; homicide; and other external violence. 



XIV. ILL-DEFINED DISEASES. 

The following titles will include only those conditions ill-defined by the phy- 
sician, whether from lack of sufficient data, or because the disease was ill-defined, or 
because the physician was negligent in making a complete diagnosis. 



USUAL CAUSES OF DEATH 



507 



177. Dropsy. Include: Anasarca; ascites; oedema of the extremities or gener- 

alized oedema; organic lesion (not defined). — Do not include: (Edema of 
the new-born (151) ; oedema of the glottis (88) ; oedema of the lungs 
(95) ; oedema of the brain (64). 

178. Sudden Death. Include: Syncope (followed by death). — Do not include: 

Puerperal sudden death (140), or sudden death followed by an explana- 
tion, as "diabetic" (50) or "apoplectic" (64). 

179. Ill-defined or Unspecified Causes of Death. Include: Exhaustion or 

cachexia or debility (of adults); asthenia; adynamia; ataxo-adynamia ; 
coma; asthenic, hectic, colliquative, synochal, gastric, bilious, or pituital 
fever; gastric involvement; fever of dentition; paralysis of the heart (in 
German " herzlahmung" or " herzschlag." in English "heart failure"); 
cyanotic asphyxia (without indicated cause, the new-born excepted) ; or 
any other insufficient diagnosis. — Do not include: Exhaustion, cachexia or 
debility of the old (154) ; fever, ataxo-adynamic (1), continued (1), sum- 
mer, or hay (99) ; asphyxia by external cause (156 or 174) ; cyanosis of 
the new-born (152). 

180. Stillbirths. Stillbirths are not included among deaths, as a stillborn child 

is one born dead. Nevertheless, it is wise to have a separate heading for 
them, including under congenital debility (151) and unknown (179) cases 
where the child lived after birth and a cause of death cannot be assigned. 

The following death certificate is used in duplicate in Pennsylvania. 

RETURN OF A DEATH 



IN THE CITY, TOWN, OR TOWNSHIP OF 



5- 



Physician's Certificate 



1 . Full Name of Deceased 

i Chinese, 

2. Color, State if< Japanese, 

(Indian. 

3- Sex, 

(Widow, 

4. Single, Married, State \l< widower 

(Divorced. 



Years,. 
Age, ^ Months, . . 



Year, . . 
Month, 



Date of j 
Death, \ 

Days, t Day 

(If age is less than one day, give hours "> 



No Certificate will be accepted 
which is MUTILATED, ILLEGI- 
BLE, INACCURATE, or any por- 
tion of which has been ERASED, 
INTERLINED, CORRECTED, or 
ALTERED, as all such changes im- 
pair its value as a Public Record. 



Duration, 



b 7. Cause of Death, 



r Chief, Mos. 

( Contributing, Mos. 



Days,. 
.Days, 



J&g=This Certificate must not 
be issued for any other ptirpose 
than as a report to the Board of 
Health. Should the Physician 
issue a duplicate, it must be 
distinctly marked "Duplicate," 
and state why issued. 



M.D. 



Residence, 



The new record for Philadelphia for 1906 adds : 

I hereby certify that I attended deceased from 190. ... to 

190 , that I last saw h.... alive on 190...., and that death 

occurred on the date above at m. 



CHAPTER XXXI 

REFERENCES UPON POST-MORTEM TECHNIC 

The elaborate list of references pertaining to post-mortem technic 
and medicolegal autopsies, published in the second (1905) edition of 
this work, has been omitted in the present instance. The literature 
upon these subjects has, however, been revised to date, and the author 
will be glad to enter into correspondence with those desiring infor- 
mation in regard to this matter, or, indeed, upon any other subject 
coming within the scope of this book. Virchow's work, " Die Sections- 
technik im Leichenhause des Charite Krankenhauses" 1874, — English 
translation by T. P. Smith, 1876, — has made a deep impress upon 
post-mortem technic, while Orth's Compendium der pathologisch-ana- 
tomischen Diagnostik nebst Anleitung zur Ausfuhrung von Obduc- 
tionen, 1900, a new edition of which is now in the course of prepara- 
tion, is the best work with which to study pathology at the post- 
mortem. Among other books in the German language which are to 
be recommended are those of Nauwerck, Sectionstechnik, Jena, 1904; 
Chiari, Pathologisch-anatomische Sektionstechnik, 1894; Busse, Das 
Sektions-Protokoll, 1903; and Graupner and Zimmermann, Technik 
und Diagnostik am Sektionstisch, 1899. In French, the works of 
Letulle, La pratique des autopsies, Paris, 1903; and Zilgien, Manuel 
theorique et pratique des autopsies, Paris, 1905, are the most recent 
and best. The more important works in English are Hektoen's The 
Technic of Post-Mortem Examinations, 1894; Blackburn's Manual 
of Autopsies, 1892; Kelynack's Post-Mortem Handbook, 1899; and 
Schmidt's A Brief of Necroscopy, 1902. Chapters upon the method 
of making autopsies are to be found in many books upon pathology, 
such as those of Coplin, Mallory and Wright, Delafield and Prudden, 
Hamilton, and Woodhead. Quain's Dictionary of Medicine and 
Wood's Reference Handbook of the Medical Sciences also give special 
articles upon this subject. Works upon medicolegal medicine, such as 
Witthaus and Becker, Peterson and Haines, and Draper, contain much 
information in regard to the proper performance of autopsies. The best 
reproductions of pathologic tissues are to be found in the Pathologic 
Atlas of Kast and Rumpel and the Medicolegal Atlas of Adolf Lesser. 

508 



INDEX 



Abbreviations used in weights and meas- 
ures, 395 

Abdomen, embalming cadaver through, 
302; enlargement of veins of, 70, 95; 
regional landmarks of (epigastric, hypo- 
gastric, right and left hypochondriac, 
right and left iliac, right and left lum- 
bar, umbilical); striae (linece albicantes) 
of, 70 

Abdominal cavity, bile in, 97; chyle in. 
97; closure of, xx, p. 298, Figs. 175, 
176; examination of organs of, 15, 17, 
vi, p. 89, 125, x, p. 172, 289, xxix, p. 
484, Plate one, Figs. 55=57, 62, 71, 
96=125, 164 = 166, 168; examination 
of organs of, in animals, 392, xxv, p. 
407, Figs. 187-191, 198, 199; fluid 
in, 95; foreign bodies in, 30, 99; gas 
in, 94; gastric contents in, 98; removal 
of organs of, in one piece along with 
those of the thoracic cavity, 125, 289 

Abdominal pregnancy, see Extra-uter- 
ine PREGNANCY 

Abnormalities, see Malformations and 
under the organs themselves 

Abomasum, Fig. 198 

Abortion, 70, 221, 294, 330, 334, 446, 
466 

Abrachius (upper limbs absent, lower 
limbs well formed) 

Abrine, toxicology of, 463 

Abscess (amoebic, atheromatous, cold or 
chronic, embolic, miliary, pericecal, 
perinephritic, perityphlitis retropha- 
ryngeal, subdiaphragmatic, subphrenic, 
tropical, etc.), see anatomic name of 
part 

Absence, see the parts themselves 

Acacia solution, 370 

Acardia, 126 

Acarus folliculorum {Demodex folliculo- 
rum), 358; A. scabiei, 358 

Accessory, see the organs and parts them- 
selves 

Accident insurance, 52 

Accidents, 506; of pregnancy, 503 

Acervuloma of brain, 267 

Acervulus cerebri, see Brain sand 

Acetanilid, toxicology of, 463, 465 

Acetic acid, toxicology of, 463, 469; uses 
of, 47, 369 

Acetone, 47, 233 



Achirus (without hands) 

Acholia (deficiency or absence of the 
secretion of bile) 

Achondroplasia, 258 

Achorion Schonleinii, Plate five 

Achromatopsia, 83 

Acid, see the acids themselves 

Acids, toxicology of, 468 

Acne, 42, 71 

Aconite, toxicology of, 463, 464 

Aconitine, toxicology of, 463, 464 

Acrania (partial or total absence of the 
cranium) 

Acrodynia, 388 
i Acromegaly, 65, 79, 81, 107, 233, 240, 

257 
i Actinomycetes, 307 
I Actinomycosis, 48, 72, 306, 327, 492 

Acute, see the diseases themselves 
! Addison's disease, 33, 69, 134, 162, 191 

495 
! Adenitis, 161, 332, 351 
J Adenoids, 139, 156, 157, 158 
I Adenoma (alveolar, cystic, fibrous, papil- 
lar, tubular; adenocarcinoma, adeno- 
cystoma, adenofibroma, adenomyoma, 
adeno myxoma, adenosarcoma), see the 
parts themselves 

Adipocere, 53, 57 

Adiposis dolorosa (Dercum's disease), 68 

Adnexa, uterine, diseases of, 496 

Adonis, toxicology of, 466 

Adrenalin (the internal secretion of the 
adrenal glands, which may when intro- 
duced into animals in sufficient quan- 
tity cause atheroma and even aneu- 
risms), 191 

Adrenals, accessory, 190; atrophy of, 
191; cancer of, 191; Coccidia of, 366; 
cortical substance of, 15; cysts of, 191; 
diseases of, 33, 190; Echinococcus of, 
191; examination of, 15, 17, 186, 187, 
190, 295, 486, Fig. 192; examination 
of, in animals, 430; gliomata of, 191; 
hsematoid degeneration of, 191; hsemato- 
mata of, 191; hydronephromata of, 190; 
hypertrophy of, 191; intermediary sub- 
stance of, 15; internal secretion of 
(see Adrenalin), 191; measurements of, 
190, 404; medulla of, 15; melanomata 
of, 191; nerves of, 15; of babe, anatomy 
of, 290; sarcoma of, 192; tuberculosis 
of, 191, 192; tumors of, 191; vessels 
of, 15; weight of, 394, 396, 404 

509 



5i° 



INDEX 



iEgagropilus (bezoar, hair ball, a con- 
cretion found in the alimentary tract, 
especially of ruminants) 

Aerobic organisms (those which require 
oxygen for growth) 

iEstivo-autumnal malaria, 364, 365 

Affection, see Disease 

African lethargy, see Sleeping sick- 
ness 

Agaricus bulbosus, toxicology of, 465 

Age, apparent, 64; estimation of, 64, 481; 

Agglutination, 128, 132 

Ague, see Malaria 

Ainhum (a disease of negroes, starting as 
a furrow in the toe, usually the little 
toe, with enlargement and destruction 
of the proximal ends) 

Air bubbles in blood, 134; emboli, 112; 
passages, foreign bodies in, 161 

Albinism, 69, 85 

Albuminuria, 334, 503 

Alcohol, toxicology of, 60, 68, 109, 130, 
150, 154, 226, 229, 231, 232, 237, 261, 
264, 278, 459, 460, 463, 465, 469, 
495; uses of, 41, 42, 45, 47, 245, 
250, 369 

Alcohol-lamp, 41, 42 

Aldehyd, formic, see Formaldehyd 

Aleppo boil (an Oriental furuncle, occur- 
ring especially on the face, and due to 
a specific bacillus) 

Algor mortis, 56 

Alienation, forms of, 496 

Alimentary tract, see parts and diseases 
themselves; measurements of, 402; 
weight of, 394, 402 

Alkalies, toxicology of, 202, 466, 470 

Alkaptonuria, 217, 234 

Allantoic cysts, 76 

Alopecia, 71 

Altmann's solution, 375 

Amanita phalloides, 460, 466 

Amanuensis, duties of, at postmortem, 
24, 489 

Amaurosis, 464 

American Anthropometric Society, 5; in- 
surance standard of weight, 395 

Ammonia, aromatic spirit of, 47; test for, 
55; to remove iodin stains, 302; toxi- 
cology of, 29, 465, 466, 470; use of, by 
injection, as a test for death, 55 

Amoeba coli (A. dysenterice) , 229, 315, 
364 

Amcebiasis, 130 

Ampulla of Vater, examination of, 199 

Amputation, complications of, 504; mus- 
cular twitching in limbs after, 54; of 
hand, in spreading gangrene, 52 

Amussat's hammer, 254 

Amyl nitrite, toxicology of, 31, 465, 467 

Amyloid concretions (bodies) occur in the 
prostate and in nervous tissue 



Amyloid degeneration, 143, 150, 209, 213, 
337; reaction for, 206, 224; turpentine 
as a cause of, 460 

Amyotrophic lateral sclerosis, 257 

Anaemia (cytogenic, essential, idiopathic, 
von Jaksch's, parasitic, pernicious, 
primary, secondary, simple, splenic, 
symptomatic, etc.), 129, 130, 138, 139, 
140, 324, 325, 331, 362, 495; definition 
of, 129; pernicious, 69, 81, 129, 130, 
134, 135, 136, 199, 206 

Anaerobic organisms (those which do not 
grow in oxygen), 385, 386, 389 

Anaesthesia, fatal, 294 

Anasarca, 310 

Anastomosis, 153 

Anatomic wart, 51; treatment of, by 
X-rays, 52 

Anatomical Board, bodies for, 5 

Anatomy, comparative, 67; morbid, see 
the diseases, and the names of the dis- 
eases under the various organs; path- 
ologic, 67; study of, at postmortems, 3 

Anchylostoma americanum, 183; A. cani- 
num, 183; A. duodenale, 129, 135, 362 

Anencephalus, 76 

Aneurism (anastomotic, arteriovenous, 
cavernous, cirsoid, congenital, cylin- 
dric, dissecting, false, fusiform, hernial, 
infective, miliary, mycotic, racemose, 
saccular, spurious, traction, traumatic, 
true, varicose, etc.), 82, 104, 105, 
115, 144, 151, 152, 153, 154, 155, 259, 
337, 497; electrolysis in treatment of, 
154; of abdominal aorta, 154; of ani- 
mals, 154; of aorta, 124; of bones, 288; 
of brain, 153; of carotid, 125; of cceliac 
axis, 154; of femoral artery, 153; of 
gluteal artery, 153; of heart, 112, 144, 
150, 151; of hepatic artery, 154; of 
mesenteric artery, 154; of sinus of 
Valsalva, 146, 154; of splenic artery, 
154; of thoracic aorta, 154, 199; of 
valves, 147; rupture of, 69, 106, 153, 
200 

Aneurismal varix, 153 

Angina, Vincent's, 313 

Angina pectoris, 143, 497 

Angioma (arterial, cavernous, fissural, hy- 
pertrophic, lymphatic, plexiform, race- 
mose, simple, varicose, and venous), 
107; of bladder, 216; of kidneys, 214; 
of liver, 230; of ovaries, 219; of skin, 
73; of spleen, 178 ' 

Angiomalacia, 149 

Angioneurotic oedema, 71, 73 

Angiosarcoma of nasal passages, 156 

Angiosclerosis, 149 

Anguillula stercoralis, 129 

Angular method of removing calvarium, 
238, Figs. 129=137 

Anhydraemia, 129 

Anideus, 76 



INDEX 



5li 



Anilin colors, toxicology of, 463, 464, 467, 
468 

Animal holder, 391, Fig. 184; parasites, 
pathogenic, 357; poisons, 460, 463, 478 

Animals, see Ape, Cat, Cow, Dog, Guinea- 
pig, Horse, Mouse, Pig, etc.; actinomy- 
cosis of, 407; aneurism in, 154; anthrax 
of, 407; arsenical poisoning of, 471; 
contagious diseases derived from do- 
mestic, 306, 407; hair-seams of, 409; in- 
oculation of , 390, Figs. 185, 186; meth- 
ods of killing, for post-mortem examina- 
tions, 408; post-mortem examination 
of, xxv, p. 407; removal of extremities 
of, 409; removal of hide of, 408, 430; 
taking temperature of, Fig. 183; value 
of necropsies upon, 407; weight of, 429 

Animation, suspended, 53 

Ankylosis, 81, 281; mistaken for post- 
mortem rigidity, 60 

Annotto, toxicology of, 464 

Anomalies, 3, 15, 235 

Anopheles claviger, 364 

Anophelina, 364 

Anonychia, acquired, 87 

Anthracosis, 33, 109, 122, 168, 226 

Anthrax, 48, 72, 135, 203, 214, 293, 308, 
407 

Anthropometric Society, American, 5 

Antifebrin, toxicology of, 467 

Antimony, toxicology of, 460, 462, 463, 
464, 465, 470 

Antipyrin, toxicology of, 71, 463, 464, 
467 

Antiseptic dressings, 45, 46, 47 

Antiserum test for diagnosing blood, 
132, 396 

Antitoxin of diphtheria, 132; of glanders, 
see Mallein; of tetanus, 52 

Antrum of Highmore, 156, Figs. 173, 
174 

Anuria, 468 

Anus, diseases of, 30, 79, 294, 336, 338, 
339, 500; examination of, 15, 17, 420, 
482 

Aorta, diseases of, 116, 124, 144, 147, 148, 
150, 151, 154, 199, 208, 351; examina- 
tion of, 15, 16, 17, 117, 120, 208, 485, 
Fig. 122; examination of, in animals, 
413, 414, 415, 416, 417, 418, 430; measure- 
ments of, 124, 401; weight of, 394, 401 

Aortic valve, diseases of, 144, 149, 152; 
measurements of, 400, 401 

Aortitis, 152 

Aparathyroidism, 108 

Ape, syphilis of, 335 

Aphonia, 465 

Apncea, 32 

Apodia, 80 

Apomorphine, toxicology of, 466 

Apoplexy (see also Brain, hemorrhage 
of, and Lung, hemorrhage of), 56, 
163, 189; mistaken for alcoholism, 32 



Appendices epiploicse, diseases of, 99, 
186 

Appendicitis (catarrhal, follicular, gan- 
grenous, obliterative, parasitic, sup- 
purative, tuberculous, typhoid, ulcer- 
ative, etc.), 134, 178, 183, 184, 185, 322, 
347, 355, 501 

Appendix, ensiform, 105 

Appendix vermiformis, 183; actinomyco- 
sis of, 308; articles found in, 184 
bacteriology of, 184; Bilharzia of 
184; cancer of, 185; catarrh of, 184 
causing subdiaphragmatic abscess, 172 
concretions in, 183; cysts of, 185 
diseases of, see Appendicitis; dupli- 
cation of, 183; enteroliths of, 184; ex- 
amination of, 15, 100, 183, 487; foreign 
bodies in, 183; gangrene of, 184, 185; 
in hernia, 185; measurements of, 183, 
402; mesentery of, 183; of babe, anat- 
omy of, 290; opening of, 180; parasites 
in, 184; perforation of, 185; sarcoma of, 
185; situation of, 30, 185; typhoid le- 
sions of, 353; ulceration of, 185; Vir- 
chow's dictum concerning, 100; weight 
of, 402; worms in, 184 

Aphthae, 78 

Apus (without a foot) 

Arachnoid, 16, 398 

Arecaline, toxicology of, 464, 465, 466 

Argyria (argyriasis), 69, 464 

Army, United States, autopsies in, 22 

Aromatic oils, toxicology of, 31; spirits of 
ammonia, use of, 47 

Arsenic as a normal constituent of the 
body, 47; detection of, in intestinal 
tract, by X-rays, 471; toxicology of, 
32, 57, 72, 129, 178, 203, 212, 221, 264, 
310, 450, 452, 459, 460, 461, 462, 463, 

464, 465, 466, 468, 470; uses of, 302 
Arseniuretted hydrogen, toxicology of, 

465, 467 

Arterial embalming, 302; varix, 152 

Arteries, diseases of, 118, 149, 152, 154, 
268, 497; examination of, 15, 16, 17, 
113, 116, 117, 122, 240, 242, 417, 486. 
487 

Arterioliths, 152 

Arteriosclerosis, 142, 144, 149, 150, 153. 
173, 337 

Arteritis obliterans (obliterative), 261 

Arthritis (acute, ankylosing, deformans, 
fibrinous, gonorrhoea^ gouty, infective, 
multiple, neurogenous, obliterans (ob- 
literative) , pneumococcal, purulent, 
rheumatic, scarlatinal, serofibrinous, 
serous, spinal, syphilitic, toxic, tuber- 
culous, ulcerative, uric, etc.), 139, 141, 
151, 275, 277, 278, 280. 319, 324, 325, 
329, 332, 350, 504 

Arthropathies, 259 

Ascaris (A. lumbricoides, A. megalo- 
cephalia, A. mystax), 129, 182, 361 



512 



INDEX 



Ascites, 70, 75, 95, 96, 129, 133, 174, 227; 
chylous, 362 

Ascospore (a spore lying within a special 
spore-case or ascus), Plate five 

Asiatic cholera, see Cholera, Asiatic 

Asomata, 76 

Asparagus, effect of, on urine, 466 

Asparagus rust, 432 

Aspergillus bronchialis, 327; A. furrn- 
qatus, 166; A. niger, 166 

Asphyxia, 32, 113, 294, 505 

Assistants at postmortem, 6, 180 

Asthma, 130, 159, 498 . 

Atavism (congenital characteristics de- 
rived from remote ancestors) 

Ataxia, cerebellar, 261; Friedreich's, 257, 
261- hereditary, 261; locomotor, 72, 
73 136, 258, 261, 265, 337, 473, 495 

Atelectasis, 121, 160, 162 

Ateleiosis (a form of dwarfism m which 
the development of the body is delayed 
or arrested, while in progeria, q.v., it is 
accelerated), 258 

Atheroma, 70, 143, 149, 150, 208, 337, 497; 
of prostate, 222; of pulmonary artery, 

Atresia of blood-vessels of heart, 126; 
of uterus, 219 

Atrophy (acute yellow, of liver, brown, of 
heart and testicles, concentric, of heart, 
congenital, cyanotic, eccentric, of heart, 
granular, muscular, optic, progressive 
muscular, pseudohypertrophic muscu- 
lar red (Virchow's), senile, etc.), 27, 
68,' 80, 91, 106, 134, 143, 144, 207, 212, 
219, 222, 223, 224, 229, 325, 468, 501 

Atropine, effect of, on pupil after death, 
54] toxicology of, 7, 463, 468, 471 

Aurantia, toxicology of, 464 

Auricular appendices, color of, 113; con- 
traction of, 113; examination of, 117, 
118, Figs. 79, 84, 85, 167; pulmo- 
nary veins of left, 118 

Auriculo ventricular septa, 114, 117; 
valves, competency of, 116 

Author's method of fixing calvanum, 
299; of precipitating lead m the gums, 
465; of preparing frozen sections, 370; 
of removing brain in child, 291; of 
removing male genitalia without dis- 
figurement, 196, Figs. 117=119; table 
of Coroner's cases, 450 

Auto-agglutination, 128 

Autoclave, 46 

Autodigestion, 98 

Autolytic ferments, 152 

Autopepsia, 98 

Autopsy, see Postmortem; first use ot 
word, 2 

Avoirdupois weight, 394 

Axillary cellulitis, treatment of, 51 

Ayer Clinical Laboratory of the Pennsyl- 
vania Hospital, 11, 18, Fig. 4 



Azur II, 369 

Azygos veins, 17, 120, 208, 401, 418 

Azoospermia, 222 

B 

Babes, measurements of, 395; postmor- 
tems on, xviii, p. 289; weight of, 395 

Bacillus, see also Bacterium and Micro- 
organisms; difference of, from bacte- 
rium, 385; resistant spores of, 308, 393 

Bacillus anthracis, 308, 386; B. coli com- 
munis, see Bacterium coli commune; 
B. diphtheria (see Corynebacterium 
diphtheria); B. icteroides, 357, 388; 
B. leprae, (see Mycobacterium leprae); 
B. mallei (see Corynebacterium mal- 
lei); B. minutissimus sputi, 388; B. 
oedematis maligni, 386; of Chantemesse, 
314; of Friedlander, 327; of Lustgarten, 
335; of Shiga, 314, 386; B. pertussis, 
388; B. pestis, 325, 327; B. pneumoniae, 
327,332; B. prodigiosus, 91; B. proteus, 
174; B. smegmatis, 335; B. subtilis, 307, 
386; B. tetani, 340, 341, 386; B. tussis 
convulsivae, 388; B. X, 357, 388 

Bactericidal properties of bone-marrow, 
49 

Bacteriologic investigations, 41, 101, xxiii, 
p. 382 

Bacterium, see also Bacillus and Micro- 
organisms; difference of, from bacillus, 
385 

Bacterium aerogenes capsulatum, Yll , 229, 
386; B. coli commune, 31, 327, 355, 386; 
B. dysenteric, 386; B. enteritidis, 386; 
B. influenzae, 321, 327, 386; B. paratypho- 
sum, 386; B. pestis, 386; B. pneumoniae, 
386; B. proteum, 386; B. pyocyaneum, 
49, 386; B. rhinoscleromatis, 386; B. 
septicaemia? haemorrhagicum, 386; B. 
typhi murium, 386; B. typhosum, 327, 
353, 386; B. vulgare, 386 

Bag, rubber, 42 

Balantidium coli, 359 

Balls, graduated, 114 

Balsam of copaiba, toxicology of, 464 

Barium salts, toxicology of, 361, 466, 471, 
473 

Barlow's disease, 140 

Bartholinian glands, 78 

Baryta, toxicology of, 466 

Basal ganglia, Fig. 149 

Base of skull, examination of, 244 

Basedow's disease, 108, 130, 162 

Basins, enamelled, 39 

Battery fluid, case of poisoning by, 9 

Beaded ribs of rhachitis, 81 

Beale's Prussian blue, 380 

" Beaver-tailed" liver, 204 

Beclard's sign, 292, 445, 488, Fig. 1 72 

Bedbug (Cimex), 306, 358 

Bed-sores (decubitus), 72, 75 

von Behring's cure for tuberculosis, 343 



INDEX 



513 



Belladonna, toxicology of, 463, 464, 466 

Bellows for inflating viscera, 41 

Benzaldehyd, toxicology of, 467 

Benzin, 47 

Benzokoll, toxicology of, 465 

Beriberi (dry, cedematous, and paralytic), 
264, 310, 388 

Bertillon classification of causes of death, 
32, xxx, p. 491; system of identifica- 
tion, 62 

Beta-oxybutyric acid in urine, 233 

Bezoar, see ^Egagropilus 

Bichlorid of mercury, see Mercury, bi- 

CHLORID OF 

Bichromates, toxicology of, 9, 465, 467, 
470; uses of, 245, 252 

Bier's passive hyperemia, 267 

Bigelow clamp, 38, Fig. 44 

Bile, 134, 224; examination of, 204, 224; 
Gmelin's test for, 134; in abdominal 
cavity, 97, 224; in blood, 134; in 
stomach, 200; specific gravity of, 224 

Bile ducts, diseases of, 224, 225, 226, 355; 
examination of, 15, 17, 198, 204, 223, 
Figs. 121, 122; examination of, in 
animals, 416, 426, 428, 430, Fig. 1 98 

Bilharzia hcematobia, see Distoma 

Biliary calculi, see Gall-stones 

Bilirubin, 134, 211, 223 

Biliverdin, 294 

Binoxalates, toxicology of, 466, 468 

Biologic blood-(albumin)test, 132, 396; 
differential diagnosis, 132, 396 

Birds, post-mortem examination of, 429 

Bishop, mind-reader, postmortem on, 7 

Bismarck brown, toxicology of, 369, 464 

Bismuth, toxicology of, 465 

Bistoury, probe-pointed, 238 

Bisulphids, toxicology of, 264, 463 

Bisulphites, uses of, 47 

Black urine, causes of, 217 

Bladder (the urinary bladder is here re- 
ferred to), abscess of, 215; absence of, 
216; adenoma of, 216; angiomata of, 
216; Bilharzia hcematobia of, 217, 363; 
calcium carbonate stones of, 217; cal- 
cium diphosphate stones of, 217; cal- 
cium oxalate stones of, 217; calcium 
triphosphate stones of, 217; calculi of, 
217; carcinoma of, 49, 216; casts of, 
are sometimes found ; Cysticercus of, 
218; cystin stones of, 217; deformities 
of, 78; dermoids of, 216; dimensions 
of, 404; diphtheria of, 216; diseases of, 
215, 502; distension of, 193; Distoma 
haematobium of, 217, 363; diverticula 
of, 216; double, 216; Echinococci of, 
218, 360; Eustrongylus gigas of, 218; 
examination of, 15, 17, 193, 194, 
195, 486, Figs. 107=114, 120, 164; 
examination of, in animals, 419, 430; 
exstrophy of, 216; fibroma of, 216; 
Filaria sanguinis hominis of, 218; fis- 



Bladder (continued) 

tula of, 216; gangrene of, 216; hemor- 
rhage in, 215; hernia of, 216; hypertro- 
phy of, 33, 141, 216; inflammation of, 
see Cystitis; inversion of, 216; meas- 
urements of, 404; mucous membrane 
of, 215; myoma of, 216; necrosis of, 
215; papilloma of, 216; parasites in, 
217; Pentastoma of, 218; perforation of, 
215; rigidity of, 59; rupture of, 216; 
sarcoma of, 216; traumatism of, 215, 
216; thrombosis of, 215; tuberculosis 
of, 216, 348; tumors of, 216; weight of, 
394, 404; xanthin stones of, 217 

Bladder, gall, see Gall-bladder 

Blank-books, post-mortem, 19 

Blastomycetes (yeasts), pathogenic, 72, 341 

Blastomycosis, 72 

Blebs, 72 

Bleeding, see Hemorrhage; use of word 
in court instead of "hemorrhage," 440 

Blisters on dead skin, 75, 464 

Blockley, see Philadelphia Hospital 

Blocks of wood as head-rests, 40; see also 
various figures, as 58, 126, 127 

Blood, viii, p. 126; abnormal constitu- 
ents of, 134; acidity of, 128, 468; 
alkalinity of, 128; bacteriologic exami- 
nation of, 113, 135, 382; bile in, 134; 
bilirubin crystals in, 134; blackish 
pigment in, 134; Bremer-Williamson 
reaction of diabetic, 226; Charcot-Ley- 
den crystals in, 135; coagulation 
of, 127; color of, 28; cryoscopic in- 
dex of, 127, 458; diseases of, viii, p. 
126; effects of air on, 29; examina- 
tion of, 29, 91, 126, 131, 369, 382, 
460, 481, 482, 487; extravasation of, 
139, 140, 141, 482; gas bubbles in, 
134; glycogen in, 134; hsematoidin 
crystals in, 134; in carbon monox- 
id poisoning, 474; in chlorate poi- 
soning, 128, 477; in cholera, 312; in 
diabetes, 226; in drowning, 458; in 
electric death, 454 ; in hydrocyanic 
acid poisoning, 473; in illuminating gas 
poisoning, 474; in longitudinal sinus, 
241; in malaria, 134, 364; in nitrite 
poisoning, 128; in potassium cyanid 
poisoning, 461, 473; in putrefaction, 
128; in scarlet fever, 331; in toadstool 
poisoning, 128; in typhus fever, 356; 
in yellow fever, 357; occult, in stools 
182; parasites of, 135, xxi, p. 306; poi- 
sons in, 429, xxviii, p. 468; specific grav- 
ity of, 127; spectroscopic examination 
of, 131, 460; spectroscopic test of, 474; 
staining of fluid by, 140; tumor cells in, 
134 

Blood fluke, 363; plates (plaques), 128, 
130, 135, 139, 140; pressure, 55, 149; 
serum, 41, 129, 133, 368; stains, 63, 
131; tests, specific, 132, 396 



33 



514 



INDEX 



Blood-blisters caused by costotome, 37, 
Fig. 34 

Blood-color scale, 126, Plate three 

Blood-vessels, diseases of, 126, viii, p. 
149, 261, 348; examination of, 16, 17, 
483 

Blow-pipe, 38, 43 

Boards of Health, 4, 306, 382 

Boards to stand on while making post- 
mortem, 13 

Body, see Cadaver 

Boils, 48, 234 

Bond's experiments, 33 

Bone, age of, how indicated, 68; aneu- 
risms of, 288; angioma of, 287; anky- 
losis of, 60; atrophy of, 278; carcinoma 
of, 288; chloroma of, 288; chondroma 
of, 287; Cysticerci of, 288; cysts of, 
287, 288; decalcification of, 376; dis- 
eases of, 62, xvii, p. 275, 323, 330, 504; 
dislocations of, 280; Echinococci of, 288; 
enostoses of, 287; examination of, 16, 
236, 296; examination of, in animals, 
430; exostoses of, 287; fibroma of, 287; 
fractures of, 280; haematoma of, 288; 
in lungs, 169; in muscles, 93; in tonsils, 
158; inflammation of, 263; injuries to, 
281; lipoma of, 287; marrow of, see 
Bone marrow; measurements of, 65; 
myxoma of, 288; necrosis of, 262; os- 
teoma of, 287; osteomyelitis of, 145, 
236, 281, 323; osteophytes of, 287; par- 
asites of, 287; sarcoma of, 288; super- 
numerary, of skull, 236; syphilis of, 336, 
339, 340; tuberculosis of, 350; tumors 
of, 287; X-ray examination of, 275; 
weight of, of skeleton, 396 

Bone forceps (bone nippers), 37, 42, 254, 
408; marrow, 16, 49, 130, 136, 137, 139, 
281 

Bordeaux mixture of copper, 432 

Borders of organs, 27 

Boric acid, toxicology of, 471 

Bothriocephalus latus, 129, 135, 360; B. 
mansoni, 361 

Bottle, iodoform-dusting, 42; wide-mouth, 
40, 42 

Bovine tuberculosis, 48, 342 

Bowel, see Intestine 

Bow-leg, 81 

Box for post-mortem instruments, 34 

Brachial plexus, 106 

Brachycephalic skull, 397, 398 

Brain, abscess of, 261, 263, 322, 332; ab- 
sence of, 260; acervuloma of, 267; 
actinomycosis of, 307; anemia of, 267; 
anthrax of, 310; aneurism of, 267, 268; 
blood-vessels of, 16; carcinoma of, 267; 
cerebroma of, 267; charts of, 26; chole- 
steatoma of, 267; congenital anom- 
alies of, 260; congestion of, 267, 496; 
cortical lesions of, method of section- 
ing in, 250; Cysticerci of, 267, 359; 



Brain {continued) 

cysts of, 267; diseases of, xv, p. 257, 
321; Echinococci of, 267; embolisms of, 
33, 147; encephalitis of, 33; endotheli- 
oma of, 267; examination of, 16, xiii 
p. 235, 291, 296, 483, Figs. 126-152; 
examination of, in animals, 420, 422, 
427, 429, 430; fibroma of, 267; glioma 
of, 267; gumma of, 267; hardening of, 
245, 251; hemorrhage of, 164, 255, 257, 

261, 268, 452, 496; hyperemia of, 268; 
hypertrophy of, 148; in diphtheria, 314; 
in malaria, 365; in poisoning, 461; in 
typhus fever, 356; incising of, 44; in- 
flammation of, 262; injection of, 250; 
injuries of, 449; measurements of, 399; 
oedema of, 130; osteoma of, 267; 
osteophytes of, 277, 282, 287; ped- 
uncles of, 16; sarcoma of, 267; saw- 
ing of, 243, Fig. 138; scars of, 269; 
sclerosis of, 261, 265; sectioning of, 
246; softening of, 261, 496; specific 
gravity of, 399; syphilis of, 267, 337; 
traumatism of, 261; tuberculosis of, 

262, 267, 352; tumors of, 243, 261, 267; 
vascular changes in, 267; ventricles of, 
16; volume of, 399; weight of, 243, 394, 
396, 398 

Brain cavity, injecting embalming fluid 
into, 9; knife, 35, 408, 422, Figs. 17, 
18; sand (acervulus cerebri), sand-like 
matter about the pineal gland and 
other parts of the brain; stem, weight 
of, 398 

Bran used in preservation of body, 301 

"Bread-and-butter" pleurisy, 109 

Break-bone fever, 312 

Breast, diseases of, 70, 72, 73, 91, 503; 
examination of, 15, 70, 91, 482 

Breastplate, 104, Fig. 70 

Breathing, see Respiration 

Bremer-Williamson reaction of diabetic 
blood, 226 

Bright's disease, 73, 96/157, 209, 451, 501 

Broad ligament, examination of, 15, 17 

Bromatotoxismus, 459 

Bromid, toxicology of, 463, 464 

Bromin for disinfecting wounds, 41, 42; 
toxicology of, 31, 461, 462, 465 

Bromoform, toxicology of, 31 

Bronchi, diseases of, 159, 160, 161, 163, 
321, 334, 338, 351; examination of, 15, 
17, 120, 122, 430, 485, 489, Fig. 89 

Bronchial glands, diseases of, 160, 309. 
324, 345 

Bronchiectasis, 159, 160, 161 

Bronchiogenic cyst, 159 

Bronchitis (acute, atrophic, capillary, ca- 
tarrhal, cheesy, chronic, croupous, fib- 
rinous, gangrenous, hypertrophic, plas- 
tic, purulent, subacute, suppurative, 
tuberculous, etc.), 130, 159, 160, 161, 
163, 307, 324, 355, 356, 498 



INDEX 



515 



Bronchopneumonia, 160, 166, 234, 307, 

314, 325, 356, 362, 499 
Bronzing of skin, 33, 69, 191, 464 
Brown atrophy of heart, 143; induration 

of lungs, 163 
Brunetti's chisels, 37, 256, Fig. 38 
Brush-burn, 71 
Brushes, hand, care of, 48 
Bubonic plague, see Plague 
Bucket method of opening intestines, 181, 

Fig. 97 
Buffy angina, see Diphtheria 
Buhl's disease (icterus neonatorum), 134 
Bulb for securing fluid for bacteriologic 

study, 383 
Bulbar paralysis, 257 



Cabbage club-foot, 433 

Cachexia, cancerous, 69; malarial, 491 

Cachexia strumipriva, 107 

Cacodyl, cyanid of, toxicology of, 471 

Cadaver, bacteriology of, 395; closure of, 
xx, p. 298, 489; cooling of, after death, 
56; decomposition of, 57, 480; disin- 
terment of, 480; disposition of, by will, 
5; embalming of, 9, 302, Figs. 179, 180; 
examination of, ii, p. 14, v, p. 53, 480, 
481; fluorescence of, 444; frozen, 60, 
302, 481; "found dead," 450; height of, 
395; identification of, 61; inspection 
of, 14; lividityof, 14, 57, 58, 60; meas- 
urements of, 64, xxiv, p. 394; opera- 
tions on, 3; pecuniary value of, 4; 
phosphorescence of, 444; preservation 
of, 290, xx, p. 298, Figs. 5=8, 179=182; 
putrefaction of, 481; restoration of, xx, 
p. 298; rigidity of, 60; right to dispose of, 
by will, 5; sewing up of, Figs. 175, I 76; 
situation of, after death, determined by- 
kind of clots, 128; specific gravity of, 
395; surgical operations on, 3; sym- 
metry of, 61; temperature of, 14; 
thawing of, 305, 481; transportation of, 
481; unidentified, 63; weight of, 11, 
395; wounds of, produced by gnawing 
animals after death, 482 

Caisson disease, 259 

Calcicosis, 168 

Calcification, 143, 150, 152; in bladder, 
217; in kidney, 211; in tuberculosis, 
342; of appendices epiploicse, 186; of 
arteries, 150; of cartilages, 103; of renal 
epithelium, 460; of valves, 145 

Calculi, biliary, see Gall-stones; of blad- 
der, 217; of kidney, 210, 213, 214; of 
nose (rhinoliths) , 156; of pancreas, 207, 
232, 233; of prostate, 222; of salivary 
glands, 274; of ureters, 193, 215; of 
urinary tract, 502 

Calipers, graduated, 39 

Calomel, toxicology of, 163, 466 



Calvarium, angular method of opening, 
238; circular method of opening, 236; 
clamps for holding, 38, Figs. 42=46; 
diseases of, xiii, p. 235, 339, 340; exam- 
ination of, 16, 236, 240, 483; examina- 
tion of, in animals, 421, 430, Figs. 192= 
197; French method of opening, 238 
Fig. 133; restoration of, 299 

Calx chlorinata, 47 

Calyces, dilatation of, 214 

Campecia wood, toxicology of, 467 

Camphor, toxicology of, 31, 463 

Canal of Nuck, 101 

Cancer, see Carcinoma 

Cancrum oris, 324 

Cannabinone, toxicology of, 463 

Cannabis indica, toxicology of, 463 

Cannula, 9, 38 

Cantharides (cantharidate, cantharidin, 
cantharidinate), toxicology of, 210, 213, 
215, 226, 460, 463, 464, 466, 467, 468 

Capsicum, toxicology of, 461 

Capsule of kidney, 189, 209, 210, 211, 212, 
486, Figs. 103, 104; of liver, 206; of 
organs, 25, 27; of spleen, 227; Tenon's, 
271 

Caput Medusae, 155, 227 

Carbol-fuchsin, 41 

Carbon bisulphid, toxicology of, 264. 463, 
467 

Carcass, see Cadaver 

Carcinoma (acinous, adenomatous, chim- 
ney sweepers', chorionotic, colloid, 
cylindrical, encephaloid, gelatinous, 
giant-celled, medullary, metastatic, pri- 
mary, sarcomatous, scirrhous, second- 
ary, tubular, etc.), 68, 99, 106, 130, 146, 
494, Plate four; cachexia of, 69; of 
adrenals, 191; of appendix, 185; of 
bones, 288; of brain, 267; of breast, 
70, 494; of bronchi, 161; of buccal 
cavity, 494; of choroid, 85; of ciliary 
body, 85; of clitoris, 79; of female 
genital organs, 494; of gall-bladder, 49, 
225; of heart, 148; of intestines, 183, 
201, 494; of kidney, 214; of larynx, 
158; of liver, 223, 225, 230, 494; of 
lung, 169, 201; of lymphatic glands, 
201, 207; of lymph-vessels, 155; of 
mediastinum, 161; of mesentery, 97; 
of nasal passages, 156; of oesophagus, 
124, 470; of omentum, 201; of ovaries, 
219; of pancreas, 102, 201, 207, 233; of 
penis, 78; of pericardium, 110, 112; of 
peritoneum, 97, 173, 174, 201, 494; of 
pleura, 170, 201; of prostate, 222; of 
pylorus, 201; of ribs, 111; of rectum, 
494; of skin, 73, 494; of spleen, 178, 
201; of stomach, 199, 201, 494; of 
umbilicus, 76; of uterus, 219; of va- 
gina, 221; of vulva, 78; protozoa of 
388 

Carcinosis, miliary, 173 



5*6 



INDEX 



Cardiac, see Heart 

Cardiotome, 117, Figs. 31, 32 

Cardol, toxicology of, 464 

Care of clothes removed from body, 62; 
of hands, iv, p. 45; of instruments, 34, 
44, 52; of rubber gloves, 46 

Caries, 85; of spine, 260; of teeth, 88 

Carnoy's fixing fluid, 367 

Carotid artery, aneurism of, 125; embo- 
lism of, 124; tearing of intima of, 124, 
486 

Carotid bodies, examination of, 15; 
tumors of, 125 

Cartilage, calcification of, 103; cricoid, 
108; cystic cavities of, 106; in tonsils, 
158; necrosis of, 142; xiphoid, 97 

Cartilage-knife, 103, 123, 480, Figs. 14 = 16 

Caruncula minor, 199 

Cascarilla to remove odor at autopsy, 11 

Case, leather, for instruments, 42, Fig. 53 

Castration, 130 

Casts of face, method of making, 305 

Cat, diseases of, 326, 429; postmortem 
on, 407, 408, 427 

Catarrh, 156, 157; adenoids in, 166 

Catheter, 38, 42 

Cattle, relapsing fever of, 329 

Causes of death, 447; in author's, 799 
Coroner's cases, 451; usual, Bertillon 
classification of, xxx, p. 491 

Caustics, toxicology of, 465; uses of, 55 

Cautery for bacteriologic work, 41, 42, 
389; for post-mortem wounds, 50 

Cavities, examination of, 31, 41 

Celloidin, uses of, 45, 376 

Cellulitis, 49, 52, 504; axillary, treat- 
ment of, 51 

Celluloid, strips of, for mounting spinal 
cord, 256 

Celosomia, 76 

Cephalonic skull, 398 

Cercomonas intestinalis, 359 

Cerebellum, diseases of, 260; examina- 
tion of, 16, 243, 247, 483, Figs. 144 = 
149; weight of, 398 

Cerebral, see Brain 

Cerebroma, 267 

Cerebrospinal meningitis, 310, 326, 495 

Cerebrum, see Brain 

Cervix uteri, malignant neoplasms of, 221 

Cestodes, 359 

Chain-hooks, 38, 43 

Chamois-skin, 42 

Chancre, Hunterian, or hard, 335; soft, 
336, 493 

Chancre a distance, 335, 336 

Chancroid, 78, 338 

Charcot's joint, 92, 259 

Charcot-Leyden crystals, 135, 159 

Charts, outline, of position of organs and 
their lesions, 26 

Cheek, diseases of, 77, 341; sucking gland 
of, 75 



Cheiragra, 277 

Cheiranthus, toxicology of, 466 

Chemic supplies, 41 

Chenopodium, toxicology of, 467 

Chest, barrel-shaped appearance of, 159 

Chiara's raspatory, 38 

Chicken, gangrene of comb of, due to 

ergot, 473; relapsing fever of, 329 
" Chicken-fat" clots, 128 
Chicken-pox, see Varicella 
Chimney-sweepers' dermatitis (cancer), 72 
Chisels, 37, 42, 43, 245, 254, 408, 409, 423, 

480, Figs. 36-38 
Chloasma, 71 
Chloral hydrate, toxicology of, 31, 463, 

464, 467, 472; uses of, 47 
Chlorates, toxicology of, 69, 128 
Chlorin, toxicology of, 31, 462; uses of, 

47 
Chloroform, toxicology of, 32, 84, 208 

455, 463, 467, 472 
Chloroma, 288 

Chlorosis, 69, 130, 136, 151, 495; Egyp- 
tian, 362; of plants, 432 
Chlorphenol, odor of, 32 
Cholangeitis, suppurative, 230 
Cholecystitis, acute infectious, 225 
Cholelithiasis, 226, 231 
Cholera, Asiatic, 48, 56, 58, 128, 129, 183 

311, 359, 492 
Cholera infantum, 356; nostras, 492 
Cholesteatoma, 267 
Cholesterin, 151, 210, 265 
Chondritis, 279 

Chondroma, 70, 156, 169, 170, 287 
Chordae tendineae, 15, 117 
Chorea, 146, 259, 260, 261, 388, 496; 

canine, 260; chronic hereditary, 259; 

Huntington's, 259 
Choroid, tumors of, 85 
Choroid plexus, deposits of silver in, 247; 

examination of, 483 
Choroiditis, syphilitic, 336 
Chromates, toxicology of, 9, 464, 467 
Chromatolysis, 130 
Chromium, toxicology of, 460, 461, 465, 

495 
Chrysarobin, toxicology of, 464, 467 
Chrysoidin, toxicology of, 464 
Chyle, 179 

Chyle-duct, diseases of, 207; examina- 
tion of, 207 
Chylocysts of mesentery, 173 
Chylopericardium occurs 
Chylothorax, 170 
Chylous exudate, 97 
Cicutoxin, toxicology of, 463 
Ciliary body, tumors of, 85 
Cimex lectularius, 358 
Cinchona bark, toxicology of, 464 
Circle of Willis, 269 
Circular method of removing brain, 236, 

Figs. 138, 139 



INDEX 



517 



Circulation, cessation of, as a sign of 
death, 54; diseases of, 136, 337, 497, 498 

Cirrhosis of liver, alcoholic, 226, 227; 
anthracotic, 227, 228; atrophic, 68, 70, 
227; capsular, 226, 227; cyanotic, 227, 
228; fatty, 226, 227; Hanot's hyper- 
trophic, 128, 226; hypertrophic, 128, 

226, 227; malarial, 227, 228; rhachitic, 

227, 228; scarlatinal, 227, 228; syphi- 
litic, 227, 228; tuberculous, 227, 228 

Cirrhosis of lung, 148 

Cirsoid aneurism, 152, 155 

Cladothrix, 308 

Clamps for holding calvarium, 38, Figs. 
42=46 

Classification, Bertillon, of diseases, xxx, 
p. 491; of poisons, 462 

Clavicle, examination of, 103, 104, 105, 
106, 120, Figs. 64=66 

Claws, examination of, 430 

Clay modelling in the study of anatomy, 
379 

Cleft palate, 123 

Clinical history, 61 

Clinocephalic skull, 398 

Clitoris, 79 

Cloacae, 282 

Closure of body after postmortem, xx, p. 
298 

Clothing as means of identification, 62; 
bullet-holes in, 63; examination of, 63, 
481; preservation of, 62, 63; stains on, 63 

Clots, chicken-fat, 128; currant- jelly, 128; 
fibrinous, 128, 154; of pernicious anae- 
mia distinguished from those of cancer, 
136; red, 128 

Cloudy swelling, 372 

Club-foot, 283; cabbage, 433 

Club-hand, 283 

Coagulation of blood, 127 

Coagulation necrosis, 337 

Coagulum of heart, 128; post-mortem, 128 

Coal gas, toxicology of, 462 

Coal-dust in hands, 33; in liver, 228; in 
lungs, 33; in spleen, 134 

Coat, rubber, 47 

Cocaine, toxicology of, 455, 463, 464, 468, 
472 

Coccidia, 365 

Coccyx, 68, 267 

Cockroaches as cause of disease, 306 

Codeine, toxicology of, 464 

Cceliac axis, aneurism of, 154 

Cceliac plexus, diseases of, 192, 312; ex- 
amination of, 192 

Coffee, burning of, to remove odor at post- 
mortem, 11 

Coffin used for post-mortem table, 10, 
Fig. 2 

Colchicine, toxicology of, 463, 464 

Colchicum, toxicology of, 461, 463 

Cold, death from, 455 

Cold abscess, 493 



I Colitis, 185, 186, 329, 33, 

Collapse, 463 

Collargol, 51 

Colloid degeneration, 92; of thyroid gland, 
107, 161 

Coloboma, 84, 85 _ 

Colocynthine, toxicology of, 465 

Colon, diseases of, 186; examination of, 
17, 100; examination of, in animals, 
411, 412, 413, 416, Fig. 189 

Color of eyes, 83; of fat in atrophy, 91; 
of fluid in abdominal cavity, 96; of 
hair, 86; of liver in acute yellow atro- 
phy, 224; of lungs, 109; of muscle, 92; 
of organs, 28, 29; of skin, 69; of stomach 
after poisoning, 461 

Color index, 135; scale, post-mortem, 126; 
values by kromskop, 28 

Colors, anilin, toxicology of, 464 

Colostrum, 293 ; 

Coma, 32, 134, 463 

Comedo, 358 

Comma bacillus of Koch, 311 

Common bile duct, see Ductus chole- 

DOCHUS COMMUNIS 

Comparative anatomy, 67; postmortems, 
xxv, p. 407 

Compensation of physicians as experts, 
438; for services, 437 

Compound fractures, 280 

Concretions, see Calculi 

Condyloma, 338 

Cones, graduated, 39, 115, Fig. 50 

Congenital, see various organs; debility, 
505; deformities, 76, 79, 80; dislocation 
of hip, 3, 76, 280 

Congestion, cyanotic, 58; hypostatic, 14, 
58, 69, 164, 482; of brain, 496; of kid- 
ney, 210; of liver, 228; of lungs, 140, 
148, 164, 499; post-mortem, 228 

Coniine, toxicology of, 464 

Conium, toxicology of, 461, 463 

Conjunctiva, 83 

Conjunctivitis, 83, 147, 314, 320, 322, 323, 
324, 329, 351, 464, 497 

Consistency of organs, 29, 206 

Constipation, 182, 466 

Contagious diseases derived from domestic 
animals, 306, 407 

Continued fever, see Typhoid fever 

Contour of organs, 25, 27 

Contracts between physician and patient, 
437 

Contractures, 80 

Contrecoup, 240, 449 

Convallaria, toxicology of, 466 

Convulsions, see Epilepsy 

Coplin brain-knife, 35, Fig. 17 

Copper, Bordeaux mixture of, 432; salts 
of, 465; toxicology of, 472 

Copper sulphate in treatment of actino- 
mycosis, 307; purification of drinking 
water by, 472 



i8 



INDEX 



Cor villosum, 111 

Cord, see Spinal cord 

Cords, vocal, examination of, 157, 158 

Cornea, 84 

Cornell head-rest, 38, 235, Fig. 46 

Cornutine, toxicology of, 463, 465 

Coronary arteries, 116; diseases of, 118, 
143, 144; examination of, 15, 113, 116, 
117, 485 

Coronary veins, 113, 118, 485 

Coroner, 154; abolition of, 1; author's 
cases investigated for, 450; creation of, 
1; duties of, 1, 33; office of, 1, 436; re- 
ferring cases to, 4, 6 

Coroner's physician, 302 

Coronilla, toxicology of, 466 

Corpora Arantii, 144; C. cavernosa, exami- 
nation of, 196; C. quadrigemina, exami- 
nation of, 483 

Corpse, see Cadaver 

Corpus callosum, 238, 242; C. hsemorrhagi- 
cum, 219; C. luteum, 218, 219; C. spon- 
giosum, examination of, 196; C. stria- 
tum, examination of, 483 

Corpus delicti, 64, 67, 440 

Corpuscles, red, agglutination of, in 
blood-serum, 129; diameter of, 132; 
elliptical human, 132; shapes of, 132 

Corrosive acids, toxicology of, 463, 465; 
alkalies, toxicology of, 463, 465, 466; 
metallic salts, toxicology of, 465; poi- 
sons, toxicology of, 465, 467 

"Corset-line," 204 

Cortex of kidney, 209, 210, 211, 212 

Corynebacterium diphtheria, 327, 386; C. 
mallei, 318, 386; C. tuberculosis, 433; C. 
xerosis, 386 

Coryza, 156, 465 

Costochondral articulation, 90 

Costotome, 37, 38, 103, 104, 408, 480, 484, 
Figs. 33, 34 

Cotton, "flaming" of, in inoculation of 
culture tube, 388; uses of, 41, 383 

Court-plaster, liquid, 45 

Cover-slips, cleansing of, 384 

Cow, postmortem on, 407, 423; Try- 
panosoma of, 366 

Cowper's glands, removal of, 196 

Cow-pox, 388 

Coxalgia, 81, 351 

Coxitis, 208 

Cranial nerves, Fig. 140 

Craniopagus, 77 

Cranioprion, van Walsem's, 35 

Cranioschisis, 260 

Cranio tabes, 81, 286, 340 

Cranium, dimensions of, 399; examina- 
tion of, 238, 483; examination of, in 
animals, 420, 429, Figs. 192=197; 
restoration of, after removal of brain, 
299, 300; sutures of, 67 

Crede's ointment, 51 

Crenation, 129 



Creolin, 42, 47; toxicology of, 463 

Creosote, toxicology of, 32, 467 

Crepitation of lungs, how elicited, 121, 
489 

Cresol, toxicology of, 467 

Cretinism, 108, 260 

Crico-arytenoid joint, ankylosis of, 158 

Cricoid cartilages, 108; diseases of, 158 

Critical examination of organs of abdomi- 
nal cavity, x, p. 172; of organs of tho- 
racic cavity, vii, p. 103 

Crocein scarlet, 371 

Crop, examination of, 430 

Croton oil, toxicology of, 333, 464, 465, 
466 

Croup, 491 

Croupous and catarrhal pneumonia, table 
showing difference between, 167 

Croupous bronchitis, 160; pneumonia, see 
Pneumonia 

Crura of diaphragm, severing of, 247 

Cruror, 128 

Crushing, suicide by, 506 

Cryoscopy of blood, 127, 458 

Crystalline lens, 85 

Crystals, Charcot-Leyden, 159; haematoi- 
din, 134 

Csokor's method of removing thoracic 
and abdominal contents in animals, 
416 

Cubebene, toxicology of, 464 

Culture-media, 41, 42, 382, 383, 385, 388 

Cultures ( ' ' smear, " " stab , " " stroke " ) , 
389 

Cupping as a test of death, 55 

Curarine, toxicology of, 464, 467 

Curcas, oil of, toxicology of, 464 

Currant- jelly clot, 128 

Curschmann's spirals, 159 

Curvatures, lateral, 283 

Cutaneous horns, 72 

Cutis anserina, 75 

Cutting instruments, suicide by, 506 

Cyanid of cacodyl, toxicology of, 471; 
of potassium, toxicology of, 473 

Cyanmethsemoglobin, 473 

Cyanosis, 69, 138, 148, 465 

Cyanotic atrophy, 229; cirrhosis of liver, 
227; induration, 147, 149, 206 

Cyclamin, toxicology of, 467 

Cyclocephalus, 76 

Cyst (see Allantoic, Dermoid, Echino- 
coccic, Hydatid),- 75, 155; of ad- 
renals, 191; of bones, 287, 288; of 
brain, 267; of cartilage, 106; of Fal- 
lopian tubes, 218; of iris, 85; of 
joints, 287; of kidneys, 209, 210, 212; 
of nasal passages, 156; of ovary, 76, 
219; of pancreas, 207; of prostate, 
222; of retina, 85; of trachea, 159; of 
ureters, 215; of vagina, 221; sebaceous, 
82 

Cystadenoma, 107, 161 



INDEX 



519 



Cystic duct, examination of, 204, Fig. 

121; obliteration of, 225; obstruction 

of, 225 
Cysticercus celluloses, 359; of bladder, 218; 

of bone, 288; of brain, 267; of heart, 

148; of kidney, 212; of lungs, 166; of 

pericardium, 111 
Cystin stones in bladder, 217; in kidney, 

214 
Cystinuria, 466 

Cystitis, 214, 215, 216, 319, 355, 466 
Cystoma of ovaries, 219 
Cytisine, toxicology of, 463, 465, 466 
Cytogenic anaemia, 129 
Cytoglobin, 139 
Cytology, 263, 459 
Cytolysins, toxicology of, 463 
Cytolysis, 130 
Cytorrhyctes luis, 387; C. variolce, 333 



Dactylitis, 339, 340 

Daltonism, 83 

Datura stramonium, toxicology of, 460, 
471 

Daylight, substitute for, at postmortem, 
9 

Dead body, see Cadaver 

Dead-house (mortuary), 11, 13 

Death, Bertillon classification of the usual 
causes of, xxx, p. 491; duration of mo- 
tility in spermatozoa after, 54; local, 
see Necrosis; molar and molecular, 
372; pathologic, 53; physiologic, 53; 
signs of, 14, 53, 482; sudden, 33, 54, 
144, 294, 503, 507; tests of, 55; time 
after, to make postmortem , 7, 480; 
violent, 1, 442, 448 

Death certificate, form of, 507; mask, 
making of, 305; rattle, 54; stiffening 
(rigor mortis), 14, 30, 59, 311, 331, 334, 
443 

Debility, 505 

Decalcification of tissues, 376 

Decapsulation of kidney, 3, 190 

Deciduoma malignum of uterus, 219 

Decomposition, 29, 30, 57, 61, 459, 482 

Deer, postmortem on, 409 

Deformities (acquired, asymmetrical, con- 
genital, multiple, muscular, nervous, 
orthopaedic, pathologic, single, sym- 
metrical, etc.), 15, 76, 78, 80, 81, 82, 
91, 124 

Degeneration, amyloid, 143, 150, 206, 224, 
460; calcareous, 103, 143, 145, 150, 
152, 211, 217, 460; colloid, 92, 107, 161, 
355; fatty, 143, 144, 145, 147, 150, 212, 
223, 225, 228, 229, 233, 234, 460, 484; 
glycogenic, 134, 206 

Dejerine's method of examining brain, 
249, Figs. 149=151 

Deleterious gases, absorption of, 506 



Delhi boil, 367 

Delirium, 257, 463 

Dementia, paralytic, 259, 337 

Demodex folliculorum (Acarus folliculo- 
rum), 358 

Dengue, 312 

Dental engines used in sawing calvarium, 
36 

Dentition, state of, in determining age, 67 

Deodorants, 41 

Dercum's disease, 68 

Dermatitis, 358; chimney-sweepers', 72; 
exfoliative, 71; Rontgen ray, 72 

Dermatitis herpetiformis, 72; venenata, 
72 

Dermatomyositis, 72 

Dermoid cysts of bladder, 216; of lungs, 
169; of mediastinum, 161; of ovary, 
191, 219, 502; of testicles, 222; 'ol 
uterus, 220 

Dermopathies, 259 

Development centre, 76 

Dextrocardia, 126 

Diabetes insipidus, 141; mellitus, 31, 73, 
97, 127, 130, 134, 231, 232, 233, 234, 
261, 341, 495 

Diabrosin, 142 

Diacetic acid in urine, 233 

Diagnosis, biologic differential, 132, 396; 
hypothetical, provisional, or tentative, 
320, 440; pathologic, 24 

Diaphanous test, 54 

Diaphragm, diseases of, 99, 163, 207, 208; 
examination of, 15, 16, 17, 95, 207, 289, 
484, 488, Figs. 67, 72, 122; examina- 
tion of, in animals, 410, 415, 417, 418, 
426, 430 

Diarrhoea, 465, 500 

Diastasis, 280 

Diazo-reaction, 353 

Dicephalus, 77 

Differentiation, optic, 374 

Digestion, post-mortem, 98 

Digestive apparatus, diseases of, 499, 501 

Digitalis, toxicology of, 113, 147, 463, 
466 

Dilatation of heart, 107, 119, 147; of 
lower rectum, 155; of lymph- vessels, 
155; of pupils after death, 54, 56; of 
superficial abdominal vessels, 155 

Dimensions, see Measurements of, under 
the various organs and parts 

Diphtheria, 78, 90, 119, 129, 130, 132, 151, 
156, 157, 160, 202, 216, 261, 264, 312, 
313, 314, 324, 326, 491, 492; Coryne- 
bacterium of, 386, Plate five 

Diplegia, spastic, 266 

Diplococcus, cultures of, 385; D. ery- 
sipelatis, 316; D. intracellularis menin- 
gitidis, 310, 386; D. pneumoniae, 166, 
262, 327; D. rheumaticus, 330 

Diploe, 237, 240 

Diplopia, 464 



20 



INDEX 



Diprosopus, 77 

Dipterce in stomach, 200 

Dipygus, 77; D. parasiticus, 77 

Directors, grooved and curved, 38, Fig. 4 1 

Discission (division) 

Disease (see also the names of the va- 
rious organs), Addison's, 33, 69, 134, 
162, 191, 495; Barlow's, 140; Basedow's 
(Graves's), 108, 130, 162; Duchenne's, 
see Ataxia, locomotor; Duke's, 324; 
Friedreich's, 257; Gilford's, 258; Gle- 
nard's (splanchnoptosis, enteroptosis, or 
abdominal ptosis), 70, 173; Graves's 
(Basedow's), 108, 130, 162; Henoch's, 
139; Hodgkin's, 130, 138, 173, 326; 
von Jaksch's, 138; Little's, 266; Osier's, 
138; Paget's, of nipple, 70, 366; Park- 
inson's, 264; Raynaud's, 265; von Reck- 
linghausen's, 267 

Diseases, Bertillon classification of, 491; 
contagious, derived from domestic ani- 
mals, 306, 407; contracted at postmor- 
tems, 48; diagnosed by agglutinative 
reaction, 128, 132; due to hsematozoa, 
364; due to micro-organisms, xxi, p. 306; 
due to parasites, xxi, p. 306; due to 
specific organisms or protozoa not yet 
isolated, 308; ill-defined, 506; of blood 
and blood-vessels, viii, p. 126; of bones, 
xvii, p. 275; of brain, xv, p. 257; of 
cord, xv, p. 257; of genito-urinary 
tract, xi, p. 209; of heart, viii, p. 126; 
of joints, xvii, p. 275; of liver and its 
ducts, xii, p. 223; of lymph- vessels, viii, 
p. 126; of nervous system, xv, p. 257; 
of pancreas and its ducts, xii, p. 223; of 
plants, xxvi, p. 432; of respiratory tract 
and accessoryfparts, ix, p. 156; of spinal 
cord, xv, p. 257 

Disinfection, 41, 47, 306, 392 

Disinterments, 480 

Dislocations, 30, 76, 80 

Dissecting apron and sleeves, 42; forceps, 
42, 43 

Distoma, 135; D. haematobium, 363; of 
bladder, 217, 363; of kidney, 212; of 
liver, 230; of lungs, 166; of ureters, 
193, 215; D. hepaticum, 363; of ali- 
mentary tract, 363; of liver, 230; of 
peritoneum, 172; D. lanceolatum of 
liver, 230; D. ophthalmobium, 363; D. 
pulmonale, 166; D. ringeri, 363; D. 
Westermanni of lungs, 166 

Diverticula, Meckel's, 178, 180; of blad- 
der, 216; of duodenum, 198; of oesopha- 
gus, 124, 198, 200; of stomach, 198 

Dochmius duodenalis, see Anchylostoma 

DTJODENALE 

Dog, chorea of, 260; Coccidia of, 366; 
Echinococcus of, 360; postmortem on, 
407, 408, 427, Figs. 199, 200; rabic, 
care of, 320; Trypanosoma of, 366, 367; 
uncinariasis of, 362 



Dolichocephalic skull, 397, 398 

Dose, lethal, 313 

Dothienenteritis, see Typhoid fever 

Dourine, 366 

Drains in dead-house, 11 

"Drill" bones, 93 

Dropsy (see also Ascites), 137, 507 

Drowning, 75, 456, 485, 505 

Duchenne's disease, see Ataxia loco- 
motor 

Ductus arteriosus Botalli, 17, 115, 126, 
146, 148, 151, 290, 443, Fig. 167; 
D. choledochus communis, 15, 17, 198 
204, 226, 355, Figs. 121, 122 

Duke's fourth disease, 324 

"Dum-dum fever," 367 

Duodenum and its ducts, 198; divertic- 
ula of, 198; examination of, 15, 17, 
198, 485, 486, 487, Figs. 121, 122; 
examination of, in animals, 413, 414, 
416, 417, 426, 428, Fig. 189; measure- 
ments of, 402; pancreatic tissue in. 
199; ulcers of, 178; weight of, 402 

Dupuytren's contracture, 283 

Dura mater, arteries of, 240; blood in, 
241; examination of, 16, 240, 241, 
255, 483, Figs. 133, 134; examination 
of, in animals, 421, 423; French method 
of opening, 239, Fig. 134; gummata of, 
244; hemorrhage in, 241, 242, 244; 
hyperaemia of, 242; inflammation of, 
244; sarcoma of, 230; tubercles of, 
244; tumors in, 241, 244; veins of, 240 

Dura-tongs, 38, Fig. 39 

Dusts, irritating, toxicology of, 464 

Dwarfism, 65, 80, 258 

Dyscrasia, 97 

Dysentery, 128, 183, 185, 283, 314, 356, 
492 

Dystrophia, 87 



Ear, diseases of, 77, 314, 340, 497; exam- 
ination of, 15, 16, 245, xvi, p. 270, 430, 
483, 488, Fig. 160 

Ecchymoses, 75, 83, 113, 142, 214 

Echinococci, 75, 360; of adrenals, 191; 
of animals, 407; of appendix, 185; of 
bladder, 218; of bone, 288; of brain, 
267; of diaphragm, 207; of heart, 148; 
of kidney, 212; of liver, 501; of lungs, 
169; of pericardium, 111; of pleura, 
170; of spleen, 178; of ureters, 215, 219 

Eclampsia, 224, 496, 507 

Ecthyma, 72 

Ectopia, 78, 126 

Ectopic pregnancy, see Extra-uterine 

PREGNANCY 

Ectromelus, 76 

Eczema, 71, 72, 73, 78, 142, 351, 358 

Egyptian chlorosis, 362; mummies, 1, 133 

Elasticity of organs, 30 

Elder pith, uses of, 368 



INDEX 



521 



Electric contractility in body after death, 
54; engine, 36, 236; fan, 11; light over 
post-mortem table, 12; ose, 41; shock, 
75, 454, 506; treatment of aneurism, 154 

Electrocution, 7, 74, 454, 506 

Electrolysis, 105; aneurism treated by, 
154 

Elephantiasis, 78, 155, 222, 227, 362 

Elephantiasis Arabum, see Elephantiasis j 

Emaciation, 68, 139 

Embalming, 1, 302 

Emboli and embolism, 112, 115, 124, 144, 
151, 152, 153, 154, 160, 163, 229, 285, 
498; air, 112; fat, 163; of liver-cells, 
224 

Embryos, fixation of, 380; measurements 
of, 397; method of determining age of, ! 
397 

Emetine, toxicology of, 465 

Emphysema of liver, 229; of lungs, 81, 
105, 109, 148, 164, 165, 325, 499; of 
mediastinum, 106 

Empyema, 156, 169, 322, 329 

Encephalitis, 322, 495 

Enchondroma of ovaries, 219; of tes- j 
tides, 222 

Encysted parasites, 100 

Endarteritis, 150, 151, 222, 269, 337 

Endocarditis (diphtheritic, fetal, fibrous, 
gonorrhoeal, malignant, mycotic, rheu- 
matic, septic, syphilitic, ulcerative, 
vegetative, verrucose, etc.), 48, 112, j 
139, 145, 146, 147, 151, 153, 202, 211, I 
220, 230, 314, 317, 320, 322, 325, 329, 
330, 332, 334, 355, 356, 497 

Endocardium, diseases of, 144, 146, 332; 
examination of, 117 

Endocervicitis, 319 

Endocyma, 77 

Endometritis (atrophic, catarrhal, decid- 
ual, diphtheritic, fibrous, gangrenous, 
glandular, gonorrhoeal, hypertrophic, I 
interstitial, mycotic, purulent, syphilit- 
ic, tuberculous, ulcerative, villous, etc.), 
220, 221 

Endophlebitis, Chiari's, 228; fibrous, 155 

Endothelioma of brain, 267; of lungs, 169; 
of lymph-vessels, 155; of ovaries, 219; 
of peritoneum, 172; of pleura, 170 

Endothelium, 152 

Engines, dental and trephining, 36 

Engorgement of lungs in pneumonia, 327 

Enlargement, see Hypertrophy 

Enostosis of bone, 287 

Ensiform appendix, 105 

Enteric fever, see Typhoid fever 

Enteritis, 314, 362, 500 

Enteroliths, 183 

Enteroptosis, 70, 173 

Enterorrhagia, 142 

Enterotome, 37, 42, 43, 117, 408, 480, 
Figs. 31, 32 

Enzymes, toxicology of, 463 



Eosin and methylen blue stain, Jenner's. 
369 

Eosinophils, 130, 140, 362, 477 

Ephedrine, toxicology of, 464 

Epicardium, 113 

Epidemic affections, 492; cerebrospinal 
meningitis, 310, 326, 495; dysentery, 
492 

Epididymis, 15, Figs. 117=119 

Epiglottis, 15, 17, 157, 338; examination 
of, 270 

Epilepsy, 260, 463, 496; cortical, 261; 
Jacksonian, 261 

Epilus, 258 

Epiphyses, condition of, in determining 
age, 67; fractures of, 141 

Epispadias, 78, 79 

Epistaxis, 142, 157 

Epithelial nephritis, 209 

Epithelioma, 72, 124, 156, 158, 221 

Equinia, see Glanders 

Equinum equiperdum, 366 

Erb's paralysis, 92 

Ergot, toxicology of, 463, 466, 473 

Ergotism, 73, 182, 460, 463, 465 

Erlicki's solution for fixing tissues, 375 

Eruptions, cutaneous, 71, 73 

Erysipelas, 49, 157, 178, 316, 326, 492 

Erythema, 71, 72, 73, 388 

Erythrocytes, 128, 129 

Erythromelalgia, 129, 150, 261 

Essential anaemias, 219 

Ether as a freezing agent, 370; toxicology 
of, 32, 264, 267, 463, 472 

Ethereal oils, 32, 467 

Ethyl chlorid, 41, 370 

Eustrongylus gigas, 218 

Evisceration of cadaver, 17, 289, Fig. 94 

Exalgin, toxicology of, 465 

Examination, medicolegal, xxviii, p. 440; 
of abdominal cavity, vi, p. 89, x, p. 
172; of animals, xxv, p. 407; of exte- 
rior of body, 53; of nasopharynx, eyes, 
and ears, xvi, p. 270; of new-born, 
xviii, p. 289; of plants, xxvi, p. 432; 
of skull and brain, xiii, p. 235; of 
thoracic cavity, vii, p. 103; order of, ii, 
p. 14; restricted, xix, p. 295 

Examiners, medical, 1 

Exanthematous typhus, see Typhus fever 

Excitomotor alkaloidal poisons, 463 

Exencephalus, 76 

Exhumation, 480 

Exophthalmic goitre, 83, 107, 162, 233, 
495 

Exophthalmos, 272 

Exostosis, 142, 156, 287 

Expert, definition of, 438 

Expert testimony, 437, 438 

Exploratory punctures, 74 

Exstrophy, 216 

Exterior of body, examination of, v, p 
53, 481 



522 



INDEX 



Extrameningeal hemorrhage, 142 
Extra-uterine pregnancy, 101, 129, 218 
Extravasations, 142, 482 
Extremities of animal, removal of, 409 
Exudates, 31; chylous, 97; differentia- 
tion of, from transudates, 96; encap- 
sulated peritonitic, at navel, 76; fibri- 
nous, 111; hemorrhagic, 97; inflamma- 
tory, 96; milky, 97; suppurative, 97 
Eyes, diseases of, 33, 83, 85, 141, 230, 325, 
340, 427, 430, 468, 497; examination 
of, 15, 16, 55, 83, xvi, p. 270, 297, 482, 
488, Fig. 1 60 



Face, examination of, 483 

Facial angle of Camper, 397 

Facies Hippocratica, 54 

Fseces, 182, 225, 412 

Fallopian tubes, diseases of, 218, 348; ex- 
amination of, 17, 195. 486, Figs. 1 1 5, 
116 

Falx, detachment of, 241 

Fan, electric, for ventilating, 11 

Farcy, 318, 319, 492 

Fat, examination of, 68, 91, 113, 285, 396 

Fat embolism, 233, 285; necrosis, 99, 207, 
231 232 

Fatty' degeneration, 143, 144, 145, 147, 
150; of heart, 484; of kidney, 212; of 
liver, 223, 225, 228, 229; of marrow 
281; of pancreas, 233, 234 

Fatty infiltration, 143, 144; of heart, 
143; of liver, 206, 229; of pancreas, 
232 

Favus of stomach, 203 

Fecal fistulse, 500 

Fehling's solution, 467 

Felon, 282, 355 

Female genital tract, diseases of, 218, 494; 
examination of, 193 

Femoral hernia, 101 

Ferments, autolytic, 152 

Fever, see the various fevers by name 

Fibrin, 151 

Fibroid heart, 119, 148 

Fibroma, Plate four; of bladder, 216; 
of bones, 287; of brain, 267; of breast, 
70; of heart, 148; of intestines, 183; 
of kidney, 214; of larynx, 158; of 
liver, 230; of lungs, 169; of nasal 
passages, 156; of ovaries, 219; of peri- 
toneum, 172; of pleura, 170; of pros- 
tate, 222; of testicles, 222; of tonsils, 
158; of uterus, 219, 220; of vagina, 221 

Fibro myxoma in nasal passages, 156 

Fibrosis of aortic valves, 149; of heart, 
144; productive, 155 

Ficker's test, 353 

Fig blight, 432 

Fttaria sanguinis hominis, 135, 155, 172, 
212, 362 

Filicic acid, toxicology of, 463 



Finger, deformities of, 78 

Finger-cots, 40, 42, 47 

Finger-nails in syphilis, 336 

Finger-prints, 62 

Finger-stalls, 40, 42, 47 

Finsen light, 52 

Firearms, wounds by, 448, 506, Plate six 

Fish as cause of leprosy, 322; cancer of, 
108 

Fish poisoning, 464 

Fissure, see Fistula 

Fistula, bronchial, 159; cervical, 82; fecal, 
500; tracheal, 159; tuberculous, 349; 
urethrorectal, 79 

Fistula in ano, 347 

Fixation, choice of agents for, 371 

"Fixing" of " smear" preparation, 384 

Fixture, electric, gas, and water, 12, Figs. 
12, 13 

Flax twine, 42 

Flaxseed poultices for post-mortem 
wounds, 51 

Flea (Pulex) as cause of disease, 306; as 
cause of plague, 325; common, 358; 
Trypanosoma of, 366 

Flemming's solution, 375 

Flies as cause of disease, 306 

Floating lobe of liver, 102 

Florence test, 459 

Fluid, ascitic, 95, 96, 109, 133, 368; em- 
balming, 302; hydrocelic, 368; preven- 
tion of escape of, from large cavities, 
41; removal of, from abdominal cavity, 
95 

Flukes, 363 

Fluorescence, 444 

Fluorescin, 55 

Fly, Spanish, see Cantharides; tsetse, 366 

Foetus, absence of post-mortem rigidity 
in, 60; examination of, 289, 380; 
measurements of, 397; percentage of 
water in, 396; post-mortem expulsion 
of, 53 

Follicular conjunctivitis, 497 

Fontanels, examination of, 291, 398, 488 

Food, impurities of, 1 

Foot, ulcer of, 259, 482 

Foot-and-mouth disease, 317, 388, 407 

Foramen of Monro, opening of, 247; of 
Winslow, 204 

Foramen ovale, 118, 126 

Forceps, forms of, 38, 42, 43, 418, 480, 
Figs. 21, 40 

Foreign bodies in abdominal cavity, 99; 
in appendix, 184; of heart, 148; in 
larynx, 158; in stomach, 200; in uterus, 
221 

Formad pocket-case, 42, Fig. 53; post- 
mortem record, 19 

Formalin (formaldehyd, formic aldehyd) 
toxicology of, 32, 463, 464, 473; uses of, 
9, 27, 41, 42, 47, 69, 98, 245, 252, 302, 
370, 377 



INDEX 



5 23 



Formates, toxicology of, 467 

Formic acid, toxicology of, 467 

Fourth disease, Duke's, 324 

Fourth of July tetanus, 340 

Fractures, 30, 80, 81, 141, 163, 449, 506; 

compound, 280; of skull, 1, 236, 237, 

244; of vertebral column, 253, 483 
Fragilitas ossium, 258 
Fragmentation of heart, 143 
Frambcesia, 317 
Freckles, 71 
French method of opening calvarium, 

238, Fig. 133; of opening dura, 239, 

Fig. 134 
Friedreich's ataxia, 257, 261; disease, 

257 
Fright, death from, 208, 472 
Frog, effect of strychnine on, 193 
Froriep's incision of spinal cord, 256 
Frozen bodies, 60, 302, 305, 481, 506; 

sections, 13, 370 
Fuchsin, toxicology of, 467 
Fungi, poisonous, toxicology of, 466 
Funnel-breast, 81 
Furuncle, 504 
Furunculosis, 72 



Gabbett's solution, 41 

Galactotoxismus, 460 

Gall-bladder, absence of, 226; bacterio- 
logic examination of, 205; cancer of, 
225; Distoma hepaticum of, 363; ex- 
amination of, 16, 101, 203, 204, 205, 
206, 426, Figs. 121, 122; inflammation 
of, 225; measurements of, 403 

Gall-ducts, examination of, 101, 486, 487; 
nematodes of, 361 

Gall-stones, 75, 101, 182, 200, 225, 226, 
229, 232, 501 

Galton's laws of inheritance, 3 

Gamboge, toxicology of, 463 

Ganglion, 287; cerebral, 16; cervical, 125; 
cceliac, 233; Gasserian, 297; semilunar, 
192; spinal (intervertebral), 320; Wris- 
berg's, 110, Fig. 74 

Ganglion cells, 136 

Gangrene, 49, 52, 71, 151, 234, 325, 355, 
504; carbolic acid causing, 468; of 
appendix, 184; of bladder, 216; of 
diabetics, 234; of extremities, 149; of 
intestines, 173; of legs, 332; of lungs, 31, 
159, 164, 165, 504; of lymph-glands, 
73; of mesentery, 173; of penis, 78; 
of tonsils, 158; of vagina, 221; senile, 150 

Gangrene foudroyante, 177 

Gas, see Emphysema 

Gas fixtures over post-mortem table, 9, 
12, Figs. 12, 13 

Gases, deleterious, 462, 506 

Gas-forming organisms, 94 

Gasserian ganglion, examination of, 297 



Gastrectasis, 201 

Gastric contents, examination of, 41, 199, 
460 ; ulcer, 98, 199, 201, 500 

Gastritis (acute, alcoholic, atrophic, ca- 
tarrhal, chronic, croupous, diphtherit- 
ic, glandular, hypertrophic, mycotic, 
parenchymatous, suppurative, toxic, 
etc.), 136, 201, 202, 203, 362 

Gastrophilus equi is frequently found in 
the stomach of the horse 

Gastroptosis, 70, 173 

Gastrorrhagia, 142 

Geese, relapsing fever of, 329 

Gelatin, uses of, 41, 379 

Gelatin of Wharton, 291 

Gelsemine, toxicology of, 463, 464 

General considerations, i, p. 1; paralysis of 
insane, 261 

Genitalia, diseases of, 136, 218, 222, 502, 
503; examination of, in animals, 408, 
409, 419, 430; female, examination of, 
15, 17, 193, 482, 486, 488, Figs. 106- 
114; male, examination of, 15, 17, 196 
482, 485, 486, Figs. 117=119 

Genito-urinary tract, diseases of, xi, p. 
209, 347, 501 

Genu extrorsum, 81; G. valgum, 81, 282; 
G. varum, 81 

German measles, 331 

Gersuny's method, 3, 301 

Gestation, intra-uterine, period of, 444, 
487 

Giacomini's method of hardening brain, 
252 

Giant-cells, 342 

Giantism, 65 

Giemsa stain, 369 

van Gieson's stain, 369 

Gilford's disease, 258 

"Gill openings," 159 

Gilson's solution, 375 

Glacial acetic acid for detecting abra- 
sions of the hands previous to perform- 
ing postmortem, 45; for treating post- 
mortem wounds, 47, 50, 52 

Gland, mammary, see Breast; parathy- 
roid, see Parathyroid gland; pineal, 
see Pineal gland; pituitary, see Pitu- 
itary gland; sucking, 75; thymus, see 
Thymus gland; thyroid, see Thyroid 
gland 

Glanders, 48, 135, 156, 222, 318, 407, 492 

Glands, lymphatic, see Lymphatic 
glands; mesenteric, in tuberculosis, 
100, 355 

Glandular fever, 319 

Glass balls, graduated, 39, Fig. 51; slides, 
41 

Glaucoma, 272 

Glioma of adrenals, 191; of brain, 267; 
of coccyx also occurs; of retina, 85 

Glisson's capsule, 206 

Globulin, 108, 133 



5 2 4 



INDEX 



Glomerulonephritis, 209 

Glossary index, 33, 508 

Glossina palpalis, 366 

Glottis, oedema of, 465 

Gloves, rubber, 40, 42, 46, 47 

Glycogenic reaction of blood, 134, 206 

Glycosuria, 162, 233 

Gmelin's test for bile, 134 

Goat, meningitis of, 310; postmortem on, 
407, 425 

Goitre, 83, 107, 108, 161, 162, 233, 260, 
495 

Golgi's method, 369, 375 

Gonococcus of Neisser, 135, 174, 221, 319, 
385, 386, Plate five 

Gonorrhoea, 48, 78, 146, 156, 264, 283, 319. 
326, 493 

"Goose-flesh" skin in drowning, 75 

Gout, 141, 145, 154, 276, 495 

Graduated cones, 39, Fig. 50 

Grains, 394 

Grammes, 394 

"Grand swipe," 125, Fig. 94 

Granular kidney, 209 

Granulations, Pacchionian, 240, 241 

Granuloma of iris, 85; of lungs, 121 

Grape mildew, 432 

Graves's disease, see Basedow's disease 

Gray hair, cause of, 86 

Grippe, see Influenza 

Gross specimens, preservation of, 6, 40, 
41, 42, xxii, p. 368 

Growths, new, see the tumors themselves 

Guaiacol, toxicology of, 467 

Gudden's microtome, 250 

Guinea-pig, determination of rectal tem- 
perature of, 390, Fig. 1 83; how affected 
by X-rays, 222, 455; inoculation of, 
390; postmortem on, 407, Fig. 187; 
Trypanosoma of, 367 

Gumma, 144, 336; of arteries, 152; of 
bone, 339; of brain, 267; of dura, 244; 
of kidney, 338; of liver, 228, 338; of 
lungs, 339; of respiratory tract, 338; 
of testicles, 338 

Gums, deposit of lead in, 465; diseases of, 
465 

Gunshot wounds, 144, 444, Plate six 

Gutta-percha, liquid, 45, 47 

Gyrinus natator, toxicology of, 468 



H 

Hematemesis, 142 

Haemathidrosis, 142 

Hematin, 269, 481 

Hematocele, 142, 221 

Hematoidin, 134, 211, 269 

Hematoma, 33, 142, 191, 210, 219, 

288 
Hematoma polyposum, 219 
Hematometra, 142 
Hematomyelia, 261 



Hematoporphyrin, 467 

Hematoporphyrinuria, 217 

Hematosalpinx, 218 

Hematoxylin, toxicology of, 467 

Hematozoa, 364 

Hematuria, 142, 217, 330 

Hemochromatosis, 467 

Hemoglobin, 126, 134, 135, 136, 137, 
138, 139, 211; carbon-monoxid, 126, 
474; reduced, 126; scale of, 126, Plate 
three 

Hemoglobin spectra, 126 

Hemoglobinuria, 211, 217 

Hemolymph-nodes, 173, 176, 190, 417 

Hemolysins, 463 

Hemolysis, 60, 130 

Hemopericardium, 110, 142 

Hemophilia, 139, 143 

Hemoptysis, 142, 163; parasitic, 363 

Hemothorax, 142, 170 

Hair, care of, during postmortem, 235, 
Figs. 126=128; diseases of, 87, 336, 
481; examination of, 15, 85, 86, 87, 
445, 482, 488; growth of, after death, 
86 

Hair-balls, 200 

Hairy heart, 111; tongue, 77 

Hallux valgus, 283 

Halsted's operation, 91 

Hamilton's method of hardening brain, 
250 

Hammers, 37, 42, 43, 254, 408, 480, Figs. 
21, 35 

Hand, amputation of, in spreading gan- 
grene, 52; anointing of, at postmor- 
tem, 45, 46; care of, and treatment of 
post-mortem wounds of, iv, p. 45, 105, 
242; condition of, before beginning 
autopsy, 45; disinfection of, 47 

Hand brushes, care of, 48 

Hand-bag for carrying instruments, 41 

Hanging, death by, 124, 456, 485, 505 

Hanging drop, 368 

Hangnails, 47 

Hanot's hypertrophic cirrhosis, 128 

Hardening of brain, advantages of, 245; 
of tissues, 371 

Harelip, 78 

Harke's method for examining naso- 
pharynx, 270, Figs. 161, 162 

Hay fever, 157 

Head, actinomycosis of, 307; examina- 
tion of, 16, 235, 482, 488; examination 
of, in animals, 420; measurements of, 
397 

Head rests, 13, 40, Figs. 45, 46, 126, 
127, etc. 

Headache, 257 

Health, Boards of, 1, 306, 382 

Heart, abnormalities of, 112, 115, 126; 
abscess of, 144, 145; actinomycosis of, 
148; aneurism of, 110, 112, 144, 145 ; 
150, 151; anthrax of, 309; asystoli^ 



INDEX 



525 



Heart {continued) 

disease of, 173; atrophy of, 148, 149; 
carcinoma of, 148; chordae tendinese of, 
15; circulation of lymph in, 113; co- 
agula of, 128; color of, 112, 122; con- 
sistence of, 113; coronary arteries of, 
15; Cysticerci of, 148; degenerations of, 
143; dilatation of, 107, 119, 147, 159, 
160; diseases of, viii, p. 126, 129, 130, 
155, 497; double, 126; Echinococci of, 
148; examination of, 15, 17, 112, 114, 
115, 295, 485, 488, 489, Figs. 74=85, 
164, 167; examination of, in animals, 
418, 419, 430; fatty degeneration of, 
485; fibroid, 119; fibromata of, 148; for- 
eign bodies in, 148; gummata of, 148; 
hemorrhage of, 224; hyaline degen- 
eration of, 143; hypertrophy of, 107, 
110, 112, 119, 142, 145, 147, 148, 150, 
224; in asphyxiation, 113; in chlorosis, 
136; in cholera, 312; in diabetes, 234; 
in digitalis poisoning, 113; in diph- 
theria, 145; in goitre, 162; in leuco- 
cythaemia, 137; in malaria, 365; in 
plague, 326; in pneumonia, 329; in 
poisoning, 461; in progressive per- 
nicious anaemia, 135; in relapsing fever, 
330; in rheumatism, 331; in scarlet 
fever, 332; in smallpox, 334; in typhoid 
fever, 355; in typhus fever, 356; in 
yellow fever, 357; incisions of, 114, 

117, Figs. 76-85; infiltrations of, 143, 
145; leaflets of, 117; lipomata of, 
148; lymphatics of, 15; lymphosarco- 
matosis of, 148; malformations of, 
126; measurements of, 112, 400; mili- 
ary tubercles of, 148; muscle-fibres of, 
143; myomalacia of, 148; myxomata 
of, 148; opening of, to discover air 
emboli, 112; papillary muscle of, 15; 
Pentastomata of, 148; plexus of, 15, 
17, 110, 290, Fig. 74; polypi of, 128, 
148; rhabdomyoma of, 148; rigidity of, 
113, 485; rudimentary, 126; rupture of, 
144; sarcoma of, melanotic, 111; soft- 
ening of , 146; suturing of, 3, 112; syph- 
ilis of, 144; thrombosis of, 128; trabec- 
ular of, 15; tuberculosis of, 144, 148, 
348; tumors of, 148; ulcers of, 145; 
valves of, 15, 115; sclerosis of, 337; 
valvular lesions of, 210, 228, 331; vol- 
ume of, 401; weighing of, 394; weight of, 

118, 119, 396, 400; wounds of, 3, 112 
Heart muscle, color of, 119; consistence 

of, 119; fibres of, 143; fibrosis of, 337 
Heart-emboli, 308 
Heat-stroke, 7, 125, 455 
Heberden's nodosities, 277 
Height of body, 64, 65, 66, 395 
Hellebore, toxicology of, 466 
Helvella esculenta, toxicology of, 465, 467 
Hemiatrophy, facial, 71 
Hemiplegia, 258, 261, 266 



Hemorrhage, 56, 93, 106, 111, 125, 130, 
139, 140, 142, 153, 173, 203, 207, 215, 
218, 220, 224, 231, 242, 244, 260, 261, 
266, 268, 325, 452, 496, 498, 502, 503; 
per diapedesis, 142; per rhexin, 142; pe- 
techial, 203; post-partum, 142; punc- 
tate, 157; varieties of, 142 

Hemorrhagic infarct, 121, 122, 140, 142, 
144, 151, 173, 177, 211 

Hemorrhoids (internal, external), 155, 215 

Henoch's purpura, 139 

Hepatic artery, 154, 204, Fig. 122; duct, 
examination of, 205, Figs. 121, 122; 
peritoneum, mechanical irritation of, 3 

Hepatitis, 228, 229, 338, 355 

Hepatization, 327, 328, 489 

Hereditary ataxia, 261; chorea, 259 

Heredity, 3 

Hermann's solution, 375 

Hermaphrodite, 64 

Hernia, 15, 78, 82, 99, 101, 153, 500; 
of bladder, 216; of diaphragm, 99, 163, 
207; of omentum, 172; of vagina, 221 

Herophilus, 1 

Herpes, 78, 259, 322 

Herpes zoster, 71, 261 

Hessee's method for test-tube culture, 
389 

Heteralius, 77 

Heterotyphus, 77 

Hewson's preservative injection, 304 

Hexenmilch, 293 

Hey's saw, 35, Fig. 24 

Hide of animal, removing of, 408, 428, 
430 

Hip-joint, congenital dislocation of, 3, 
76, 280 

Historical considerations, 1 

Hobnail liver, 206, 227 

Hodgkin's disease, 130, 138, 173, 326 

Hofmann's treatment of decomposed 
body, 57 

Hog, see Pig 

Homicide, 448 

Hone, 39, Fig. 21 

Hoof, examination of, 430 

Hooks, double, 480 

Horns, examination of, 430 

Horse, death of, from electricity, 455; 
diseases of, 360; Trypanosoma of, 366; 
postmortems on, 407, 408, 409, 410, 
Figs. 189=193 

Horse-flesh, specific blood-test for, 396 

Horseshoe kidney, 210 

Hour-glass contracture of stomach, 100 

Huntington's chorea, 259 

Hutchinson's teeth, 88, 339, 340 

Hyaline degeneration, 143, 150, 220 

Hydatids (see also Echinococci), 75, 360 

Hydremia, 128, 129 

Hydrarthrosis, 276, 280 

Hydrocele, 78, 222, 459 

Hydrocephalus, 260, 261, 398 



26 



INDEX 



Hydrochloric acid, toxicology of, 32, 
469 

Hydrocyanic acid, toxicology of, 56, 57, 
58, 128, 135, 189, 463, 467, 473 

Hydrofluoric acid, toxicology of, 462 

Hydromeningocele, 260 

Hydromyelia, 266 

Hydronephroma, 190 

Hydronephrosis, 193, 210 

Hydropericardium, 110 

Hydrophobia, see Rabies 

Hydrosalpinx, 218 

Hydrostatic test for pneumonia, 121, 122, 
167, 419; for viability, 443, 489 

Hydrothorax, 170 

Hygroma, 287 

Hymen, 79 

Hyoid bone, fracture of, 81 

Hyoscyamine, toxicology of, 464, 465, 
468 

Hyoscyamus, toxicology of, 463, 464, 466 

Hyperemia of brain, 242, 268; of liver, 
228, 229; of lungs, 162; of spleen, 
137 

Hyperinosis, 128 

Hypernephroma heterotopes of kidney, 
215 

Hyperplasia, 137, 138 

Hypertrophy (see also the various or- 
gans), 27 

Hypinosis, 128 

Hypobromite solution, 47 

Hypodermic injections, 74; syringe for 
inoculation of animals, 390 

Hypogastric artery, Fig. 164 

Hypoplasia of aorta, 151; of cerebellum, 
260; of circulatory and generative or- 
gans in chlorosis, 136; of uterus, 219 

Hypospadias, 78, 79 

Hypostasis, 113 

Hypostatic congestion of lungs, 58, 69, 
164 

Hypothetic diagnosis, 440 

Hypsicephalic skull, 397 

Hysterectomy, vaginal, Figs. 106=114 

Hysteria, 257, 261, 496 



Icard's test for presence of life, 55 

Ichthyosis, 72 

Ichthyotoxismus, 460 

Icterus, 57, 69, 130, 134, 183, 217, 227, 
329, 365, 506 

Icterus neonatorum, 134 

Ictrogen, toxicology of, 465, 466, 467 

Identification of body, 61, 62 

Idiocy, 260 

I.-E. (immunity-unit) of German litera- 
ture, 313 

Ileocecal valve, 179, 182 

Iliac arteries, curvature of, 30; fossa, ab- 
cess of, 501 



Illuminating gas for preserving the natu- 
ral color of specimens, 378; toxicology 
of, 58, 264, 450, 473 

Imbibition, 60, 146, 487 

Immunity (an excellent series of articles 
appeared upon this subject in the 1905 
numbers of the Jr. of the Amer. Med. 
Assoc.), 48, 50 

Immunity-unit, 313 

Impetigo, 72 

Inanition, 100, 460, 506 

Incense to remove odor, 42 

Incising heart, kidneys, etc., see Exami- 
nation of, under the names of the vari- 
ous organs 

Incubator, 41 

Index, altitudinal, 397; cephalic, 397; 
cryoscopic, 127 

Indican in urine, 217 

Indol, odor of, 32 

Induration, cyanotic, 147, 149; of liver, 
206, 229; of skin, 73 

Infancy, early, diseases of, 505 

Infant, autopsies on, 443; new-born, au- 
topsies on, xviii, p. 289 

Infanticide, 456 

Infantile paralysis, 262 

Infantilism, 258 

Infarcts (air, anaemic, bilirubin, calcare- 
ous, fat, hemorrhagic, etc.), 121, 122, 
140, 142, 144, 151, 152, 163, 164, 173, 
177, 211, 213, 220 

Infection, post-mortem, 40, iv, p. 45; 
purulent, 492; septicemic, 492; sources 
of, 33 

Infectious fevers, see the fevers them- 
selves 

Inferior vena cava, 401, Fig. 122 

Infiltration, calcareous, 143; fatty, 143, 
144, 206; hemorrhagic, 145 

Inflammation (catarrhal, croupous, dif- 
fuse, diphtheritic, phlegmonous, syphi- 
litic, toxic, tuberculous, etc. The five 
cardinal symptoms of inflammation, 
heat, redness, pain, swelling, and inter- 
ruption of continuity, may all be absent 
at postmortem, and yet inflammation 
may have existed at the time of death. 
Read Councilman's article in Dennis's 
Surgery, Adami's in Allbutt's System 
of Medicine, and Metchnikoff's com- 
parative lectures on inflammation. 
Virchow's work op Cellular Pathology 
is of great historic value), 93, 213. 225, 
244, 309 

Influenza, 130, 135, 156, 261, 264. 321, 
326, 492 

Infusoria, parasitic, 359 

Infusorium balantidium coli, 177 

Inguinal glands in plague, 326; hernia, 
101 

Inheritance, laws of, 3 

Initial incision, 90, Figs. 58=62 



INDEX 



527 



Injected specimens, 379 

Injecting fluid, 379, 380; syringe, 391, 

480 
Injections, hypodermic, 74; of bodies, 

302; Figs. 179,180; saline, 74 
Injuries, description of, 482; extent of, 

Innominate vein, care not to injure, 104 

Inoculated tubes, cultivation of, 389 

Inoculation of animals, intravenous, 391, 
Fig. 186; intraperitoneal, 391, Fig. 185; 
subcutaneous, 391, Figs. 184 = 186 

Inoculum, preparation of, 389 

Inorganic chemic poisons, 462; irrespir- 
able gases, 462; irritant poisons, 462 

Insane, general paralysis of, 261; mal- 
position of organs in, 100 

Insanity, 257, 264; books of reference on, 
264 

Insect galls, 432 

Insolation, 506 

Instruments, bacteriologic, 41, xxiii, p. 
382; post-mortem, iii, p. 34; for ani- 
mals, 407; in Army, 43; in Navy, 43; 
sterilization of, 34, 52 

Insurance in accident companies, 52 

Insurance standard of weight and height, 
395 

Intercarotid bodies, 125 

Intercranial hemorrhage, 452 

Interments, premature, 53 

Intermittent fever, 491 

International system of nomenclature of 
diseases and causes of death, xxx, p. 
491 

Interstitial nephritis, 62, 211; pancreati- 
tis, 231; pneumonia, 166 

Intestines (see also Colon, Rectum, Duo- 
denum, etc.), actinomycosis of, 308; 
adenoma of, 183; adhesions of, 178; 
bucket method of examining, 181, Fig. 
97; carcinoma of, 183, 201, 494; 
cleansing of, 180, 181; color of mu- 
cous membrane of, 181; diseases of, 
181, 322, 500; Echinococcus of, 360; ex- 
amination of, 15, 17, 46, 178, 179, 180, 
484, 486, 487, 488, Plate one, Figs. 96= 
99, 164; examination of, in animals, 
408, 409, 413, 414, 416, 417, 428, 430; 
fibroma of, 183; gall-stones of, 182; 
gangrene of, 173; hemorrhage of, 142, 
183; hernia of, see Hernia; ileocecal 
valve of, 179, 182; inflammation of, see 
Peritonitis; lipoma of, 183; measure- 
ments of, 402; myoma of, 183; Nema- 
todes of, 98, 361; obstructions of, 500; 
parasites of, 182, 500; perforation of, 
213; polypi of, 181, 183; sand of, 183; 
sarcoma of, 183; serous covering of, 
100; syphilis of, 337; tuberculosis of, 
346; tumors of, 183, 494; tying of, 98, 
Fig. 96; ulcers of, 140; weight of, 402 

Intima of carotids in strangulation, 124 



Intoxication, occupation, 495 
Intraperitoneal inoculation of animals 

391, Fig. 185 
Intra-uterine gestation, determination of 

period of, 487 
Intravenous inoculation, 391, Fig. 186 
Intraventricular septum, 114 
Intussusception (invagination), 101 
Iodin for staining of tissues, see Lugol's 

solution; toxicology of, 108, 461, 464 

465, 474 
Iodin index in determining presence of 

horse-flesh, 396 
Iodoform for post-mortem wounds, 51; 

toxicology of, 32, 463 
Iodoform celloidin solution, 42, 45 
Iodoform-dusting bottle, 42 
Iodothyrin, 108 

Ipecacuanha, toxicology of, 464 
Iris, 84, 85 

Iritis, 320, 322, 331, 336, 340 
Iron in liver, 136, 206; useful in axillary 

cellulitis, 51 
Irrespirable gases, organic and inorganic, 

462, 463 
Irritant inorganic poisons, 462; organic 

poisons, 463 
Irritating dusts, toxicology of, 464; va- 
pors, toxicology of, 464 
Ischiopagus, 77 
Islands of Langerhans, 232 
Itch, 504 
Itch-mite, 358 

J 

von Jaksch's anaemia, 138 

Jalap, toxicology of, 466 

Jars, museum, 40, 42, 487, Fig. 202 

Jaundice, see Icterus 

Jaw, actinomycosis of, 307 

Jejunum, peptic ulcer of, 182 

Jenner's stain, 369 

Jigger, 358 

Joints, diseases of, 80, 92, 141, xvii, p. 

275, 279, 285, 287, 311, 336, 339, 350, 

351, 353, 504; examination of, 16, 430, 

482 
Jones, Admiral Paul, postmortem on, 

62 
Jumping from high places, suicide by, 

506 

K 

Kairin, toxicology of, 467 
Kaiserling's method of preserving natu- 
ral color of specimens, 377 
Kakke, 310 

"Kala-azar" of Assam, 367 
Karyokinesis, 218 
Keloid, 73 

Keratitis, 84, 336, 351 
Keratosis, 72 



528 



INDEX 



Kidney (see also Nephritis, Bright's 
disease, etc.), abscesses of, 211, 213, 
214, 220; absence of, 209; accessory, 
209; adenocystoma of, 210; adrenal 
tissue in, 215; amyloid changes in, 
209, 213; angioma of, 214; anthrax 
of, 310; atrophy of, 210; Bilharzia 
hcematobia of, 212; bilirubin infarcts of, 
211; blood-vessels of, 15; calcareous, 
211; calculi of, 210, 214; cancer of, 
214; capsule of, 15, 189, 209, 211; 
cicatricial bands of, 210; coalition, par- 
tial, of, 210; Coccidia in, 366; compen- 
satory hypertrophy of, 211, 212; con- 
cretions in, 210; congenital defects of, 

209, 210; congestion of, 160, 210; con- 
tracted, 209; cortex of, 15, 189, 212; 
cyst of, 210, 212; cystic, 209; Cysticerci 
of, 212; cystin stones of, 214; decapsu- 
lation of, 3, 190; degenerative changes 
in, 213; desquamation of, 213; diseases 
of, 129, 188, 209, 502; displacement of, 
by tumors, 212; Distoma hcematobium 
of, 212; Echinococci of, 212, 360; em- 
bolism of, 147; examination, 194, 289, 
295,486, Figs. 100-104, 166; exami- 
nation of, in animals, 393, 413, 414, 
417, 419, 430, Fig. 191; fatty changes 
in, 212; fibroma of, 214; Filar ia san- 
guinis hominis of, 212; floating, 186; 
fluid in, 210; gouty, 211; granular, 189, 
212; gumma of, 338; hematoma of, 
210; horseshoe, 210; hypernephroma 
of, 215; hypertrophy of, 209, 212; in 
acute yellow atrophy, 244; in arterio- 
sclerosis, 150; in cholera, 312; in cir- 
rhosis of liver, 227; in diabetes insipid- 
us, 141; in diphtheria, 314; in dysen- 
tery, 316; in erysipelas, 317; in Malta 
fever, 324; in pneumonia, 329; in re- 
lapsing fever, 330; in scarlet fever, 
332; in smallpox, 334; in typhoid 
fever, 355; in yellow fever, 357; in- 
farcts in, 211, 220; inflammation of, 
212, 213; large white, 212; lipomata of, 
214; liver-tissue in, 215; lobulation of, 

210, 293, Fig. 166; lymphadenoma of, 
214; lymphoma of, 214; measurements 
of, 214, 403; medulla, 15, 189; method 
of distinguishing right and left, 188; 
movable, 212; myoma of, 214; myoma 
of, 214; necrosis of, 214; oxalate cal- 
culi of, 214; papilla of, 15; parasites 
in, 212; pelvis of, 15, 17; pelvis of, 
distension of, 210; Pentastoma of, 212; 
phosphate stones of, 214; pigmentary 
infarcts of, 213; poisons, effect of, 
on, 460; proliferation of, 213; pyra- 
mids of, 15; rhabdomyomata of, 214; 
right and left, distinguishing points 
between, 403; sarcoma of, 214; spe- 
cific gravity of, 403; stones in, 214; 
Strongylus gigas of, 212; syphilis of, 



Kidney (continued) 

338; tuberculosis of, 214, 347; tumors 
of, 210, 214, 215; uric acid infarcts of, 
189; vessels of, 187, 404; weight of, 
394, 396, 403; xanthin stones of, 214 

Klebs-Loffler bacillus, 160, 312, Plate 
five 

Knives, 34, 35, 42, 43, 44, 90, 408, 480, 
Figs. 14=20; method of holding, 43, 
Fig. 54, etc. 

Knock-knee, 81, 282 

"Knock-out drops," 472 

Koch controversy, 342 

Kolisko, postmortems by, 8, 435 

Kreotoxismus, 460 

Kromskop, 28 

Kyphosis, 108, 208, 257, 350 



Label, gummed, 42 

Labelling of tissues, 373, Fig. 202 

Labia, diseases of, 155 

Labor, accidents of, 503; normal, 503; 

premature, 294 
Lacerations, 30 
Laking, 130 

Lamination of clots, 153 
Lamp, alcohol, 41, 42 
Landry's paralysis, 264 
Laparotomy wound, removal of organs 

by means of, 295 
Larcher's sign, 56 
Lardaceous degeneration, see Amyloid 

DEGENERATION 

Large intestine, see Intestines 

Laryngitis, 157, 158, 324 

Larynx, diseases of, 157, 158, 257, 314, 
321, 323, 334, 336, 355, 492, 498; ex- 
amination of, 15, 17, 123, 485, 488; 
examination of, in animals, 418, 430 

Lateral curvature, 261; sinus, thrombosis 
of, 244, 332 

Lathyrism, 460 

Lavatories, 13 

Laveran's organism, 365 

Lead, toxicology of, 129, 150, 261, 262, 
264, 452, 459, 460, 463, 464, 465, 466, 
467, 474, 495 

Lecithin, 267 

Leiomyoma of uterus, 219 

Leishman-Donovan bodies, 367 

Lens, hand, 42, 480 - 

Leontiasis ossea, 258 

Leprosy, 69, 71, 72, 156, 222, 322, 323, 
492 

Leptocephalic skull, 398 

Leptomeningitis, 154, 244, 262, 263 

Leptothrix, 308 

Lesions, see diseases of the various or- 
gans, and the 'diseases themselves; 
multiple, 101 

Letulle's method of making autopsy, 17 



INDEX 



529 



Leucin, 166, 223, 468 

Leucocytes, diameter of, 132 

Leucocythsemia, 31, 106, 127, 128, 130, 
135, 136, 137, 138, 173, 175, 176, 177, 
181, 214, 495 

Leucocytosis, 106, 130, 138, 139 

Leucoderma, 69 

Leucopenia, 130 

Leucoptasia, 337 

Leukaemia, see Leucocytblemia 

Lice, 68, 357, 366 

Lichen, 72 

Liebermeister grooves, 204 

Ligaments, examination of, in animals, 
430; suspensory, of liver, 99 

Light for post-mortem examinations, 9, 
12, 480; polarization of, 467 

Lightning, death by, 454 

Lindsay Johnson's mixture, 375 

Linese albicantes, 70 

Lion-forceps, 38 

Lip, diseases of, 78, 339 

Lipaemia, 97, 130 

Lipoma, 70, 73, 75, 85, 148, 170, 183, 207, 
214, 219, 287 

Liquefaction necrosis, 152 

Liquid court-plaster, 45 

Liquor antisepticus, 47 

Literature on postmortems (see also the 
second edition of this work, and 
the many foot-notes and references in 
the text of both editions), xxxi, 
p. 508 

Lithography and three-color printing, 
28 

Lithopedion, 218 

Lithosis, 168 

Litmus paper, 41, 42, 480 

Litre, equivalents of, 395 

Little's disease, 266 

Liver (see also Bile duct, Gall-blad- 
der, etc.), abscess of, 207, 223, 229, 315, 
356; accessory lobes of, 102; acini of, 
16; actinomycosis of, 308; adenocys- 
toma of, 230; adenoma of, 230; ad- 
renal tissue in, 215; albuminoid de- 
generation of, 224; amoebic abscess of, 
207; amyloid degeneration of, 224; 
angioma of, 230; anthracosis of, 196, 
226; anthrax of, 310; atrophy of, 106, 
203, 211, 223, 224, 229, 468, 501; 
beaver-tailed, 204; blood-vessels of, 16; 
cancer of, 223, 230; capsule of, 16, 206; 
cirrhosis of, 97, 124, 177, 206, 226, 227, 
232, 233, 365, 501; coal-dust in, 228; 
Coccidia of, 365; color of, 204, 224, 
227; congestion of, 160, 228; consist- 
ency of, 206; cystic, 230; discoloration 
of, in ammonium hydrate poisoning, 
29; diseases of, 129, 155, 210, xxi, p. 
223, 321, 323, 501; Distomum hcema- 
tobium of, 230; D. hepaticwn of, 230, 
363; D. lanceolatum of, 230; Echinococci 



Liver (continued) 

of, 230, 360, 501; emphysema of, 229; 
examination of, 16, 17, 101, 203, 204, 
295, 486, Figs. 72, 75, 121, 122, 
124, 125, 164; examination of, in 
animals, 393, 413, 414, 415, 417, 418, 
428, 430; fatty degeneration of, 223, 
225, 228, 229, 362; fatty infiltration of, 
206, 229; fibroma of, 230; gumma of, 
227, 228, 338; hemorrhage from, 224; 
hob-nailed, 206, 227; hyperemia of, 228, 
229; hypertrophic cirrhosis of, 227; 
hypertrophy of, 229; in cholera, 312; 
in diabetes mellitus, 234; in dysentery, 
315; in erysipelas, 317; in Hodgkin's 
disease, 139; in leucocythsemia, 137; in 
Malta fever, 324; in measles, 324; in 
pneumonia, 329; in relapsing fever, 330; 
in smallpox, 334; in typhoid fever, 
355; in yellow fever, 357; induration 
of, 229; infectious diseases of, 230; 
literature on diseases of, 223; lobula- 
tion of, 102, 206; measurements of, 
402; melanosarcoma of, 33, 230; mili- 
ary tubercles of, 206; necrosis of, 224; 
nutmeg, 228; of babe, 290; parasites 
of, 230; passive congestion of, 228; 
Pentastoma denticulatum of, 230; poi- 
sons, effect of, on, 460; "porcelain," 102; 
Psorospermice of, 230; rhachitic cir- 
rhosis of, 228; rupture of, 33, 163, 223; 
sarcoma of, 230; situation of, 203; 
specific gravity of, 403; suspensory 
ligaments of, 99; syphilis of, 224, 227, 
230, 335, 338, 340; tracings of, 204; 
traumatism of, 30, 228, 229; tuber- 
culosis of, 206, 224, 230, 347, 349; 
tumors of, 125; volume of, 403; weight 
of, 394, 396, 402; " whisky and 
brandy," 227; yellow atrophy of, 106, 
173, 357 

Liver-cells, emboli of, 224 

Liver-fluke, 363 

Liver-rot of sheep, 363 

Lividity, cadaveric, 57, 58, 60, 61, 69, 140 

Lobar pneumonia, see Pneumonia 

Lobeline, toxicology of, 464, 466 

Lobular pneumonia, see Pneumonia 

Lobulation, see Kidney, Liver, etc. 

Locke's solution, 444 

Locomotion, diseases of organs of, 504 

Locomotor ataxia, see Ataxia, loco- 
motor 

Loesch vs. Union Casualty and Surety 
Company, 5 

Loffler's alkaline methylen blue, 41 

Longitudinal sinus, 16, 128, 241, 483 

Lordosis, 208, 283 

Lorenz's operation, 3 

Luer's rhachiotome, 35, 254, 483, Fig. 
26 

Lugol's solution, 41, 178, 224, 369 

Lumpy jaw, 306 



34 



53° 



INDEX 



Lung, aberrant tissue of, 172; abscesses 
of, 162, 220, 355; actinomycosis of, 
162, 307; adenoma of, 169; air embo- 
lism of, 163; alveoli of, 15; amyloid 
bodies of, 165; anaemia of, 163; an- 
thracosis of, 109, 122, 168; anthrax of, 
309; apoplexy of, 122, 163; atelectasis 
of, 121; blebs of, 121; bone in, 121, 169; 
brown induration of, 163, 164; cal- 
cified tubercles of, 121; cancer of, 169, 
201; carnification of, 328; cavities of, 
122; chondroma of, 169; cicatrices of, 
121; circulatory disturbances of, 163; 
cirrhosis of, 148; Coccidia in, 366; 
collapse of, 162; color of, 109, 121, 122, 
168, 169; congestion of, 148; consoli- 
dation of, 122, 148; crepitation of, 121; 
Cysticercus cellulosce of, 166; dermoid 
cysts in, 169; differentiation of left 
from right, 121; diseases of (see Pneu- 
monia, Tuberculosis, etc.), ix, p. 156; 
Distoma hcematobium of, 166; Echino- 
coccus of, 360; embolism of, 147, 163; 
emphysema of, 109, 121, 164, 165, 
499, Fig. 87; endothelioma of, 169; 
examination of, 15, 109, 120, 121, 122, 
295, 484, 485, 489, Plate one, Figs. 72, 
86=89, 94, 164; examination of, in 
animals, 393, 418, 430, Fig. 189; fat 
embolism of, 163; fibroid changes in, 
328; fibroma of, 169; gangrene of, 31, 
159, 164, 165, 355, 499; glanders of, 
318; gumma of, 339, 340; hemorrhage 
of, 121, 163, 345; hepatization of, 121, 
327, 328, 345; hydrostatic test of, 121, 
122, 167, 419, 443, 489; hypostatic con- 
gestion of, 164, 443; in cholera, 312; in 
diabetes mellitus, 234; in dysentery, 
312; in pneumonia, 327; in relapsing 
fever, 330; infarcts of, 121, 122, 163, 164, 
220; infectious granulomata of, 121; in- 
flammation of, see Pneumonia; liquid 
in, 121; lobes of, 15, 120; lobules of, 15; 
measurements of, 401; melanosarcoma 
of, 169; microscopic examination of 
scrapings of, 122; miliary tubercles of, 
121; oedema of, 164; osseous forma- 
tions in, 121, 169; osteoma of, 169; 
palpation" of, 121; parasites in, 166; 
parenchyma of, 121; passive congestion 
of, 164; pigmentation of, 121; sarcoma 
of, 169; specific gravity of, 122, 402; 
Strongylus of, 166; syphilis of, 339, 340; 
thrombosis of, 163; traumatism of, 
169; tuberculosis of, 121, 163, 168, 169, 
217, 284, 325, 334, 339, 340, 492; 
tumors of, 121, 169; vesicular emphy- 
sema of, 165; vessels of, 15; viability of 
child determined by examination of, 
443, 489; weight of, 121, 394, 396, 401 

Lupinotoxin, toxicology of, 465 

Lupus vulgaris, 72, 156, 352 

Luxations, 253, 506 



Lye, stricture due to, 124 

Lymph, circulation of, in heart, 113; 

collections of, mistaken for other lesions, 

100 
Lymph stasis, 155; tumors, 155 
Lymphadenitis, 332 
Lymphadenoma, 138, 139, 214 
Lymphangiectasis, 362 
Lymphangitis, gangrenous, 73 
Lymphangioma, 123, 155 
Lymphangioma cysticum, 155 
Lymphatic glands, diseases of, 51, 138, 

169, 201, 207, 314, 319, 329, 331, 351, 

498; examination of, 15, 17, 393, 419, 

430, 485 
Lymph-follicles, necrosis of, 353 
Lymph-glands, diseases of, 353 
Lymph-nodes, 16 
Lymphocytosis, 130, 231 
Lymphoid tissue, 138, 139 
Lymphoma, 158, 161, 214 
Lymphosarcoma, 138, 139, 148, 161 
Lymphotoxsemia, 294 
Lymph-vessels, 16, 155 
Lysol, 47, 463, 467 
Lyssa, see Rabies 

M 

Macrocytes, 135 

Macrocytosis, 129 

Macroglossia, 77, 155 

Macroscopic specimens, preservation of, 
6, 40, 41, 42, xxii, p. 368 

Macrostoma, 77 

Macules, 71 

Madura foot, 308 

Magnesium oxid, toxicology of, 452 

Magnifying-glass, 39, 480 

Magnus's test for circulation, 55 

Mai de caderas, 366 

Malachite green, toxicology of, 464 

Malacia 30 

Malaria' 71, 130, 134, 226, 261, 264, 326, 
364, 365, 407, 491 

Male fern, toxicology of, 464 

Male genital tract, see Genitalia, male 

Malformations, 30, 65, 76, 126, 156, 196, 
505 

Malignant angina, see Diphtheria; dis- 
ease, see Cancer and Sarcoma, under 
the various organs; endocarditis, 139; 
oedema, 49, 393; pustule, 309, 492 

Mallein, 318 

Mallet, 42 

Mallory's stain, 376 

Malpractice, 437 

Malta fever, 128, 135, 323 

Mammary glands, diseases of, 91, 325. 
352; examination of, 91, 293 

Mania, 130, 325 

Manometer, 55 

Marchi's method, 375 

Marine-Hospital Service, autopsies in, 23 



INDEX 



531 



Marrow, 105, 130, 137, 281, 430 

Mask, death, making of, 305 

Masland's electric saw, 37, Fig. 27 

Massachusetts General Hospital, appara- 
tus for transportation of bodies at, 
11, Fig. 9 

Massage, stiff joints prevented by, 52 

Mastoid processes, examination of, 274 

Matrix of nails, suppuration of, 52 

Maturity, determination of, 444, 487 

Maxilla, alveolar compartments in, 445 

McKinley, President, postmortem on, 6 

Measles, 31, 71, 72, 130, 156, 157, 283, 
324, 326, 388, 491 

Measles of pork, see Trichina spiralis 

Measurements (see also the various organs 
and parts), 38, xxiv, p. 394 

Measuring-glass, 39, 42, 480 

Meat, diseases of, 343 

Meat-axe, 408 

Meckel's diverticulum, 30, 178, 180, 355 

Meconium, 225, 293, 489 

Media, see Culture-media 

Mediastinitis, 106, 111, 161 

Mediastinum, diseases of, 106, 111, 112, 
161; examination of, 15, 106, 485 

Medical examiners, 1 

Medicine, changes in urine after ad- 
ministration of, 466; practice of, com- 
pensation in, 437 

Medicolegal postmortem, difference of, 
from pathologic postmortem, 2, 440; 
form of report in, 440, 489; Prussian 
regulations for performance of, xxix, p. 
479 

Medicolegal references, see second edition 
of this book; suggestions, xxviii, p. 436 

Mediterranean fever, 128, 135, 323 

Medulla oblongata, examination of, 16, 
247, 483 

Medullary leukaemia, see Leucocytile- 
mia 

Megaloblasts, 135 

Megalocytes, 135 

Melansemia, 134 

Melanin, toxicology of, 467 

Melanoma of adrenals, 191 

Melanotic sarcoma, 107, 134, 169, 191, 
217 

Melanuria, 467 

Melnikow-Raswedenkow fluid, 378 

Mendel's law (a law of heredity experi- 
mentally shown to exist by Mendel in 
1865, and but recently rediscovered, 
according to which one-fourth of the 
characteristics will be like each parent 
and the other half will possess recessive 
attributes), 3 

Meniere's disease (aural vertigo) 

Meninges, examination of, 16 

Meningitis, 48, 49, 264, 269, 310, 311, 
322, 325, 326, 329, 331, 332, 356, 493, 
495 



Meningocele, 77 

Meningococcus, 310 

Meningoencephalitis, 33, 263, 352 

Menopause, 220 

Menorrhagia, 142 

Menstruation, vicarious, 142, 143 

Mentha pulegium, toxicology of, 466 

Menthol, toxicology of, 467 

Mercaptan, 32 

Mercuric bichlorid soap, 47 

Mercury, toxicology of, 71, 221, 261, 264, 
460, 462, 463, 464, 465, 467, 468, 475 

Mercury, bichlorid of, for dressings, 42; 
for fixing tissues, 373, 375; toxicology 
of, see Mercury, toxicology of 

Mesarteritis, 151 

Mesenteric artery, aneurism of, 154, 173, 
417; glands, 100, 355 

Mesentery, diseases of, 97, 172, 173, 183, 
349; examination of, 15, 16, 17, 172, 
486, Fig. 122; examination of, in 
animals, 412, 413, 414, 417, 426, 430, 
Fig. 191 

Mesocephalic skull, 397 

Mesorectum, examination of, in animals, 
412, 414 

Metabolism, 135 

Metallic poison, postmortem on case of, 46 

Metals, acid salts of, toxicology of, 466 

Metapagus, 76 

Metastatic abscesses, 135, 145 

Meteorism in animals, 409 

Methsemoglobin, 128, 467 

Methemoglobinemia, 460 

Methyl alcohol, toxicology of, 32, 475 

Methyl chlorid, 41; as a freezing agent 
370 

Methylen blue, eosinate of, 369; Loffler's 
alkaline, 41; toxicology of, 467 

Methylen green, 369 

Metric system, 394, 482 

Metritis, 319, 502 

Metrorrhagia, 142 

Meynert's method of examining brain, 
246, 248, Fig. 149 

Micrencephaly, 260 

Microcephalic skull, 398 

Micrococcus, 387; M. albus, 387; M. ca- 
tarrhalis, 327; M. citreus, 387; M. gon- 
orrhcece, 386; M. melitensis, 323, 387 

Microcytes, 135 

Microcytosis, 129 

Microglossia, 77 

Micromegaly, 258 

Micromyelia, 260 

Micro-organisms, Plate five; anaerobic, 
385, 389; classification of, 385; cult- 
ures of, 389; diseases due to, xxi, p. 
306; effect of, on urine, 466; found at 
postmortem, 395; in appendicitis, 184; 
in peritonitis, 174; odor due to, 31; 
pathogenic, 48, 389; study of, 24; uses 
of, 432; virulence of, 49, 50 



S3 2 



INDEX 



Microscope, 41, 368, 388, 481 
Microscopic examination at postmortem, 

24, 41, 42, 368, 370, 481 
Microsomia, 80 
Micro spironema, 335 
Microtome, freezing, 35, 41, 250 
Microtome knife for incising spinal cord, 

255 
Middle ear, diseases of, 263, 314, 324, 332 
Miliaria, 72 
Miliary fever, 388, 492; tuberculosis, see 

Tuberculosa miliary 
Milk, abnormal color of, 91 
Milk spots, 111, 113 
Milky exudate, 97 
Mineral acids, toxicology of, 466 
Mirbane, toxicology of, 452 
Mitral orifice and valves, 118, 144, 147, 

400 
Mnemonic for situation of valves and 

leaflets of heart, 118 
Moisture scale, 127, Plate three 
Moles, 69, 71, 482 
Mollities ossium, 284 
Molluscum contagiosum, 366; M. fibro- 

sum, 73 
Monkey, trypanosomes of, 366 
Monsters, 76 
Morbidity statistics, 491 
Morbilli, see Measles 
Morgue, 10, 305 
Morphine, effect of, in accelerating death 

by electricity, 455; toxicology of, 455, 

459, 460, 463, 464, 465, 466, 467 
Morphcea, 71, 73 
Mortopsy, see Postmortem 
Mortuary room, 11, 13 
Morvin, 318 
Mosquitoes as disseminators of dengue, 

407; of disease, 306; of malaria, 407; of 

yellow fever, 407 
Mother's mark, see N^evus 
Moulds, see Hyphomyceles 
Mouse, anthrax of, 393; as a cause of 

pneumonia, 327; effect of electricity 

on, 455; inoculation of, Fig. 184; ma- 
lignant oedema of, 393; postmortem 

on, 407 
Mouth and its adnexa, diseases of, 77, 

339, 341, 346, 499; examination of, 

15, Figs. 90, 91, 173, 174 
Movable kidney, 212 
Mucor mucedo, 166 
Mucous canals, ascending currents in, 

33; fever, see Typhoid fever; patch, 

336, 338 
Miiller's fluid, 42, 245, 250, 252, 375 
Multiple lesions, 101 
Mummification, 57 
Mumps, 283, 324, 326, 388 
Murder, first degree, medical expert in 

cases of, 462 
Murexid test. 217 



Muscular atrophy, central, 275; progres- 
sive, 257 

Muscarine, toxicology of, 464, 465, 466 

Muscles, diseases of,' 43, 59, 60, 92, 93, 
94, 123, 136, 147, 311, 319, 355, 356, 
359, 362, 396; examination of, 16, 92; 
examination of, in animals, 430 

Museum jars, 40, 42, Fig. 202 

Mustard, 47; oil of, toxicology of, 464 

Mycetoma, 308 

Mycobacterium leprae, 322, 387; M . tuber- 
culosis, 387, Plate five 

Myelitis, 215, 264 

Myelocytes, 130 

Myelocytosis, 130 

Myeloginous leukaemia, 130 

Myelomeningocele, 260 

Myelotome, Pick's, 35, 243, Fig. 20 

Myiasis, 359 

Myocarditis (fibroid, interstitial, paren- 
chymatous, segmentary, etc.), 143, 144, 
145, 148, 234, 308, 320, 329, 330, 332, 
334 

Myocardium, examination of, 117 

Myofibroma of uterus, 219 

Myoma, 70, 158, 214, 216, 219, 220, Plate 
four 

Myomalacia cordis, 144, 146 

Myosarcoma of uterus, 219 

Myositis, 93 

Mytilotoxismus, 460 

Myxoedema, 73, 107, 108, 162 

Myxoma, 70, 156, 214, 222, 288, Plate 
four 

N 

Nabothian cysts, 221 

Namis, 71, 73, 152 

Nagana, 366 

Nails, 15, 52, 87, 488 

Narcotics, toxicology of, 466 

Nasal fossae, diseases of, 142, 156, 157, 
158, 311, 313, 318, 323, 339, 498; ex- 
amination of, 15, 16, 245, 270, 297, 
430, 488, Figs. 161, 162, 173, 174 

Nasopharynx, examination of, 270, Figs. 
160=162 

Nauwerck's method of discovering semin- 
al vesicles, 197, Fig. 120; of embalm- 
ing, 303 

Navel, see Umbilicus 

Navy, United States, autopsies in, 22 

Neck, diseases of, 75, 78, 80, 82, 307; ex- 
amination of, 90, 482, 483, 485, Figs. 
90, 91; examination of, in animals, 
418 

van Neck's picture of Ruysch, the anato- 
mist, Fig. 165 

Necropsy, see Postmortem 

Necrosis (coagulation, colliquative, fat, 
liquefaction, molecular, etc.), 73, 85, 
88, 99, 141, 147, 152, 207, 214, 215, 
224, 233, 282, 357 



INDEX 



533 



Necrospermia, 222 

Needle, aneurism, 43; post-mortem, 40, 
42, 43, 408, 480, Fig. 21 

Needles, tarnishing of, in living muscle, 
55 

Negri bodies, 320, 451 

Negroes, bones of, 67; color of skin of, 
69; malaria in, 364 

Nematode, 361 

Neoplasm, see Tumor 

Nephritis (acute, chronic, desquamative, 
diffuse, epithelial, fibrous, glomerular, 
interstitial, parenchymatous, subacute, 
tubular, vascular, etc.), 62, 110, 130, 
140, 151, 189, 209, 210, 211, 212, 213, 
234, 322, 323, 324, 330, 331, 332, 334, 
338, 356, 357, 501 

Nephrolithiasis, see Calculi, of kidney 

Nerium, toxicology of, 466 

Nerves, diseases of, 56, 85, xv, p. 257, 
310, 321, 337, 341, 497; examination 
of, 16, 242, Fig. 140 

Nettles, toxicology of, 464 

Neuralgia, 257, 324, 496 

Neurasthenia, 201, 257 

Neuritis, 259, 264, 310, 314, 388 

Neuroglia, 265 

Neuroma, amputation, 504 

Neurons, 257, 258 

Neuropathology, xv, p. 257 

Neuroretinitis, 233 

Neutral red, 369 

Neutrophilic whites, 135 

New-born departing from hospitals with- 
out having been sick, 505; determina- 
tion of maturity of, 293, 443, 444, 488; 
evisceration of, 289; examination of, 
xviii, p. 289, Figs. 164 = 172; viability 
of, 293 

New growths, see Tumors, under the 
names of the various organs and parts 

Nicotine, toxicology of, 32, 463, 464, 465, 
466 

Nipple, infection of, 70; Paget's disease 
of, 70; supernumerary, 70; tuberculo- 
sis of, 352 

Nissl's staining method, 375 

Nitric acid, toxicology of, 461, 465, 469 

Nitrites, toxicology of, 128 

Nitrobenzol, toxicology of, 32, 135, 452, 
465, 475 

Nitroglycerin, toxicology of, 465 

Noma, 313, 332 

Nomenclature of diseases and causes of 
death, international system of, xxx, p. 
491 

Non-puerperal diseases of breast, 503 

Non-venereal diseases of genital organs of 
male, 502 

"Normal" as used in pathology, 24, 
489 

Normoblasts, 135 

Nose, see Nasal fossae 



Note-book, 42 

Notes, post-mortem, 24, 441, 481, 489 

Nothnagel's method, 246 

Nozzle, injecting, 480 

iV-rays, 444 

Nuck, canal of, ovary in, 79, 219 

Nutmeg, toxicology of, 475 

Nutrition, 14, 68, 482 

Nux vomica, toxicology of, 468 



Obducent (one who makes a medicolegal 
postmortem), 441, 489, 490 

Obduction, 2 

Obesitas cordis, 143 

Obesity, 130, 396 

Objects used for comparison of size and 
shape, 27, 28, 431, Plate two 

Obstructions, intestinal, 500 

Occult blood, 182 

Ochronosis, 217, 234, 278 

Odontoma (tooth tumor) 

Odor of certain diseases, 31, 97, 487; of 
certain drugs, 31, 32, 466; of certain 
organisms, 31; post-mortem, removal 
of, 11, 47, 302 

(Edema, 31, 49, 62, 70, 71, 73, 91, 130, 
137, 140, 157, 160, 164, 209, 213, 309, 
362 

(Esophagus, abscess of, 200; cancer of, 
124; dilatation of, 124; diphtheria of, 
124, 314; diseases of, 321, 500; diver- 
ticula of, 124, 198, 200; epithelioma of, 
124; examination of, 15, 16, 17, 122, 

123, 124, 199, 200, 289, 468, 485, 487, 
489, Figs. 90=94; examination of, in 
animals, 413, 415, 418, 426, 428, 430; 
longitudinal folds of, 200; measure- 
ments of, 200, 402; peptic ulcer of, 124; 
removal of, in one piece with tongue, 
trachea, and adjacent structures, and 
subsequent examination of, 122; rup- 
ture of aneurism into, 200; stenosis of, 
337; syphilis of, 124, 337; thrush of, 

124, 341; tuberculosis of, 124, 346, 351; 
tumors of, 124, 200; typhoid ulcer of, 
124; ulcers of, 124, 200, 337; veins of, 
124; weight of, 402 

O'idium albicans, 341 

Oil, ethereal, of mustard, toxicology of, 

466; of turpentine, toxicology of, 466 
Oiled silk, 42 

Ointment, carbolic acid, 45 
Oligemia, 129, 176 
Oligocythemia, 129 
Omentum, diseases of, 30, 172, 349, 366; 

examination of, 15, 17, 99, 172, 430, 

486 
Omphalomesenteric duct, 99 
Omphalopagus, 77 
Omphalositic monsters, 76 
Onychia, 234 



534 



INDEX 



Operating table, 9, 11, 12, Figs. 1-4, 11, 
12 

Operation, Halsted's, 91; Lorenz's, 3 

Ophthalmia, 48, 330, 386 

Opium, toxicology of, 32, 84, 182, 463, 
464,466,476 

Opsonin (" preparation for a meal" — 
that quality of a serum which makes a 
microbe more easily ingested by the 
phagocytes) 

Optic nerve, 85, 258, 311; thalamus, ex- 
amination of, 483 

Optical differentiation, 374 

Oral cavity, examination of, 296; exam- 
ination of, in animals, 418 

Orang-outang, intestinal infection from 
Balantidium coli in, 359 

Orbit, diseases of, 85; examination of, 
245 

Orchitis, 322, 324, 325, 329, 338, 355 

Order of examination, ii, p. 14, 429, 486 

Organic acids, salts of, toxicology of, 466 

Organisms, see Micro-organisms 

Organs (see also the organs themselves), 
general considerations concerning, 14, 
25, 26, 27, 28, 29, 30, 102, 128 

Ornithodorus savingnyi, 358 

Orthocephalic skull, 397 

Orthognathous skull, 398 

Orth's fluid. 370, 375 

Os calcis, 293 

Ose, 41, 42, 389 

Osier's disease (chronic cyanosis), 138 

Osmic acid as a fixative, 369; odor of, 
32 

Ossification, centres of, 79, 292 

Osteitis, 283, 284 

Osteitis deformans, 81, 258, 284 

Osteo-arthropathy, 284; hypertrophic pul- 
monary, 258 

Osteochondral line in syphilis, examina- 
tion of, 292, Figs. 170, 171 

Osteogenesis imperfecta, 258 

Osteoma, 156, 169, 170, 222, 267, 287 

Osteomalacia, 30, 81, 130, 284 

Osteomyelitis, 145, 236, 281, 323 

Osteophytes, 277, 282, 287 

Osteoporosis, 278, 283, 351 

Osteosclerosis, 283 

Otitis media, 329, 351 

Otocephalus, 76 

Outline charts for recording the situation 
and extent of lesions, 26, Plate one 

Ovaritis, 319 

Ovary, abscess of, 218; absence of, 219; 
actinomycosis of, 308; adenoma of, 
219; angioma of, 219; atrophy of, 219; 
calcifications of, 219; cancer of, 219; 
cystomata of, 76, 219, 502; dermoid 
cysts of, 191, 219; enchondroma of, 
219; endothelioma of, 219; examina- 
tion of, 15, 17, 219, 419, 486, Figs. 1 1 5, 
116; fibroma of, 219; fibromyoma of, 



Ovary (continued) 

219', hypertrophy of, 219; in canal of 
Nuck, 79, 219; in mumps, 219, 325; 
lobes of, 219; measurements of, 405; 
myoma of, 219; prolapsed, 219; psam- 
mocarcinoma of, 219; sarcoma of, 219; 
supernumerary, 219; transplantation of, 
3; tuberculosis of, 219, 348; tumors 
of, 219, 502; weight of, 396, 405 

Oviducts, see Fallopian tubes 

Ox, accessory adrenals of, 190; diseases 
of, 360; Taenia saginata of, 360 

Oxalate stones of kidney, 214 

Oxalic acid, calculi of, 214; toxicology 
of, 459, 460, 461, 466, 467, 468, 469; 
use of, 47 

Oxamid, toxicology of, 466, 468 

Oxybutyric acid, toxicology of, 463 

Oxycephalic skull, 398 

Oxyhemoglobin, 474 

Oxyuris vermicular is, 200, 361 

Oysters, poisoning by, 333 

Ozena, 313, 332 



Pacchionian bodies (granulations), 16, 240, 
241, 279 

Pachycephalic skull, 398 

Pachydermia laryngis, 158 

Pachymeningitis, 241, 244, 262, 264 

Paget's disease, 70, 366 

Pails used in autopsies, 41 

Palate, 15, 77, 123, 418, 430, 485, Fig. 
91 

"Pale" as used in pathology, 28 

Palpation of organs, 29, 431 

Palsy, birth, 266 

Paludal fever, see Malaria 

Panaricium, 282 

Panarthritis, 275 

Pancreas, accessory, 199, 230; acini of, 
16; anomalies of, 230; apoplexy of, 
231; atrophy of, 233; blood-vessels of, 
16; calculi in, 207; cancer of, 102, 207, 
210, 233; cysts in, 207; degenerations 
of, 207; diseases of, 130, 207, xii, p. 
230; examination of, 16, 17, 198, 207, 
486, Figs. 121, 122; examination of, 
in animals, 413, 414, 415, 416, 426, 
428, 430, Fig. 198; f a t of, 16; fatty 
degeneration of, 233, 234; fatty in- 
filtration of, 232; hemorrhages in, 207, 
231; hyaline degeneration of, 232; 
lobulation of, 232; ' measurements of, 
405; necrosis of, 233; pigmentation of, 
232; specific gravity of, 405; syphilis 
of, 231, 232; tuberculosis of, 231; 
tumors of, 207; weight of, 394, 404 

Pancreatin, 369 

Pancreatitis (gangrenous, hemorrhagic, 
interacinous, interstitial, syphilitic, 
etc.), 231, 232 

Panniculus adiposus, 91 



INDEX 



535 



Papilloma, 124, 158, 161, 193, 216 

Papules, 72 

Paquelin thermocautery, 41 

Parabanic acid, toxicology of, 466 

Paracephalus, 76 

Paracolon infections, 181, 355 

Paraffin, injection of, to restore parts, 
3, 301 

Paraffin method of preparing tissues for 
section, 320, 376 

Paraglobulin, 133 

Paragonimus Westermanii, 363 

Paraldehyd, toxicology of, 32, 496 

Paralysis, 464; atrophic spinal, 262; bul- 
bar, 257; diver's, see Caisson disease 
Erb's, 92; essential, of children, 262 
facial, 81; general, of insane, 261 
infantile, 262, 265; juvenile, 92; Lan- 
drey's, 264; pseudohypertrophic mus- 
cular, 92; spastic, 265, 266 

Paralysis agitans, 261, 264 

Paralytic dementia, 259 

Paramecium coli, 359 

Paramidophenol, toxicology of, 467 

Paramyoclonus multiplex, 257 

Paraplegia, 81; ataxic, 261 

Paraplegia dolorosa, 267 

Parasites, see the parasites themselves, 
especially under the organs; diseases 
due to, 32, 77, 100, 129, xxi, p. 306, 357, 
500 

Parasitic haemoptysis, 363 

Paratyphoid fever, 128, 134, 135, 181, 
356 

Parathyroid glands, 15, 107, 108 

Parchment-like spots, 75 

Paregoric to remove post-mortem odor 
from hands, 47 

Parenchymatous myocarditis, 145; my- 
ositis, 93; nephritis, 212 

Parkinson's disease, 264 

Parotid gland, examination of, 483 

Parotitis, 274, 312, 324, 325, 339; cceliac 
or splanchnic, 274 

Parrot's nodes, 340 

Pasteur treatment, 320 

Patch, mucous, 336 

Pathogenic animal parasites, 357; bacteria, 
48, xxi, p. 306, 386 

Pathologic diagnosis, 24, 67, 431 

Pathology, plant, xxvi, p. 432 

Patient and physician, relations of, 436, 
437 

Pediculosis, 71 

Pediculus capitis, 357; P. corporis, 357; 
P. pubis, 357; P. vestimenti, 357 

Peduncles of brain, 16 

Pelades, 504 

Peliosis rheumatica, 71 

Pellagra, 388, 460, 463, 468, 475, 492 

Pelvic cavity, examination of, 17, 486; 
organs, removal of, en masse, 17, 289, 
Fig. 94 



Pelvimeter, 42, 480 

Pelvis, exenteration of, in animals, 419; 
female, characteristics of, 67 

Pemphigus, 72, 339 

Penicillium brevicaule, 32, 471 

Penis, 15, 78, 196, 230, 409, 419, 420, 
486, Figs. 117=119 

Pennsylvania Hospital, Ayer Clinical 
Laboratory of, 11, 18, Fig. 4 

Pentastoma, 148; P. constrictum, 359; P. 
denticulatum, 178, 230; P. tcenitoides, 
359 

Pepper dust, toxicology of, 464 

Peptic ulcers of oesophagus, 124 

Perforating ulcer of foot, 259 

Periarteritis, 151, 154, 232 

Periarthritis, 275 

Peribronchitis, 161 

Pericarditis (adhesive, fibrous, gonor- 
rhceal, productive, rheumatic, suppura- 
tive, etc.), 106, 110, 111, 159, 161, 314, 
320, 322, 329, 330, 332, 334, 355, 497 

Pericardium, adhesions of, 114; blood in, 
110; cancer of, 110, 111; Coccidia in, 
366; Cysticerci in, 111; Echinococci in, 
111; examination of, 15, 17, 29, vii, 
p. 103, 190, 484, 485, 488, Figs. 72=75, 
80, 164, 167; examination of, in ani- 
mals, 418, 428, 430; exudate in, 110; 
fluid in, 110; foreign bodies in, 111; gas 
in, 111, 112; gummata in, 111; hemor- 
rhage of, 111, 332; rupture of aneu- 
rism into, 154; sarcoma, melanotic, of, 
111; Trichina in, 111; tuberculosis of, 
110, 111; villoid projections of, 111; 
wounds of, 112 

Perichondritis, 158 

Perihepatitis, 223 

Perinephric abscess, 213 

Periosteum, examination of, 16 

Periostitis, 85, 285, 355 

Peripheral nerves, diseases of, 323; ex- 
amination of, 16, 256 

Periphlebitis, 206, 228, 229 

Perisplenitis, 227, 347 

Peristalsis, reversed, 182 

Perithelioma of carotid body, 125 

Peritoneal fluid, 109; specimen of, from 
inoculated animal, 393 

Peritoneum, 94; aberrant tissues in, 172; 
actinomycosis of, 172; cancer of, 97, 
173, 201, 494; Coccidia in, 366; Cys- 
ticerci of, 359; cysts in, 172; Distoma 
hepaticum of, 172; endothelioma of, 
172; examination of, 15, 172, 410, 430; 
fibroma of, 172; Filaria in, 172; lipo- 
ma of, 172; lung tissue in, 172; malig- 
nant tumors of, 494; mechanical irri- 
tation of, 3; tuberculosis of, 174, 349; 
tumors of, 172 
Peritonitis (adhesive, cancerous, diffuse, 
fibrinous, general, hemorrhagic, local- 
ized, proliferative, purulent, putrid, 



536 



INDEX 



Peritonitis (continued) 

serofibrinous, serous, tuberculous, etc.), 
46, 48, 76, 97, 99, 146, 159, 172, 174, 175, 
178, 218, 228, 319, 329, 355, 501 

Permission to perform postmortem, 3, 4, 
6 

Pernicious anaemia, 69, 73, 81, 129, 130, 
134, 135, 136, 211 

Pertussis (whooping cough), 130, 157, 
325, 388, 491 

Petechia; 142 

Peyer's patches, 139, 180, 181, 312, 324, 
334, 353, 354, 417, 487 

Phalloides amanita, 460, 466 

Pharyngitis, 331 

Pharynx, diseases of, 257, 314, 321, 338, 
355, 499; examination of, 15, 17, 123, 
430, 485 

Phenylendiamin, toxicology of, 452, 464 

Philadelphia Hospital, blank post-mor- 
tem record of, 20, 21 

Phlebectasia, 155 

Phlebitis, 154, 355 

Phleboliths, 152, 155 

Phlebosclerosis, 155 

Phlegmasia alba dolens, puerperal, 503 

Phlegmon, 504 

Phloridzin, toxicology of, 467 

Phosphates, deposits of, in pregnant 
women, 79 

Phosphatic calculi, 217 

Phosphorescence, 444 

Phosphorus, toxicology of, 32, 106, 129, 
143, 149, 173, 203, 215, 221, 223, 226, 
264, 452, 459, 460, 462, 463, 465, 466, 
467, 468, 476 

Photographs as means of identifying 
body, 62 

Photomicrographs, 369 

Phrenic nerves, 110 

Phthisiogenic organism described by von 
Schron, 342 

Phthisis, see Tuberculosis 

Phthisis florida, 345 

Physician practising when intoxicated, 
437 

Physician and patient, relations of, 436, 
437 

Physician's certificate for return for a 
death, 507; responsibility in judicial 
hanging, 53 

Physostigmine, toxicology of, 463, 464, 
465, 466 

Pia mater, 16, 242, 243, 398, 483 

Pick's method of preserving the natural 
color of specimens, 378; myelotome, 35, 
243, Fig. 20 

Picrates and picric acid, toxicology of, 
456, 464, 466, 469; uses of, as a fixa- 
tive, 373 

Picrotoxin, toxicology of, 463, 477 

Pig, diseases of, 343, 359, 360; postmor- 
tem on, 408, 426 



Pigeon-breast (pectus carinatum), 81, 

105 
Pigmentation, 121, 134, 136, 144, 203 
Pilocarpine, toxicology of, 464, 465, 466, 

468 
Pineal gland, 16, 247, 394, 399 
Pins, 40 

"Pipe-stem" coronary artery, 113 
Pitres's method of examining brain, 246, 

248 . 
Pituitary body, 16, 242, 244, 257, 258, 

297,394, 399, Fig. 139 
Pityriasis rosea, 71 
Placenta, 220, 294, 396 
Plagiocephalic skull, 398 
Plague, 48, 128, 325, 326, 492 
Plane, horizontal, of skull, 397 
Plants, pathology of, xxvi, p. 432, 444 
"Plaques choriales" of sheep, 79 
Plasmodium malarice, 135, 364 
Platinum loop (ose), 41, 384 
Platycephalic skull, 397, 398 
Plethora, 129 
Pleura, diseases of, 109, 121, 155, 159, 

169, 170, 201, 329, 332, 349, 360; ex- 
amination of, 15, 109, 484; examina- 
tion of, in animals, 430 

Pleurisy ("bread-and-butter," diaphrag- 
matic, dry, encysted, gonorrhceal, hem- 
orrhagic, interlobular, purulent, rheu- 
matic, etc.), 49, 75, 81, 109, 161, 169, 

170, 171, 320, 322, 328, 330, 332, 355, 
499 

Pleuropneumonia, 204; of cattle, 166 

Plexus, brachial, 106 

Plumbism, see Lead-poisoning 

Pneumatosis, 111 

Pneumococcus (Streptococcus lanceolatus) , 
135, 327, 385, 387 

Pneumogastric nerves, 15, 17, 290 

Pneumomalacia, 165, 234 

Pneumomycosis, 166 

Pneumonia (alcoholic, aspiration, catar- 
rhal, croupous, fibrinous, hypostatic, 
interstitial, lobar, lobular, syphilitic, 
tuberculous, white, etc.), 62, 109, 111, 
122, 128, 130, 146, 154, 163, 166, 167, 
234, 261, 311, 312, 323, 324, 327, 
328, 330, 331, 332, 339, 340, 345, 355, 
499 

Pneumonitis, 327 

Pneumonoconiosis, 168 

Pneumopericardium, 111 

Pneumothorax, 90, 109, 111, 170, 325 

Pockets in bladder, 216 

Podagra, 277 

Podophyllotoxin, toxicology of, 466 

Poikilocytosis, 129, 135 

Poisoning, chronic, 495; collection of tis- 
sues from cases of, 46, 441, 487; con- 
tents of stomach in case of, 41; 
questions to be answered in cases of, 
461 



INDEX 



537 



Poisons, see also Poisoning and Toxi- 
cology of, under the names of the va- 
rious poisons themselves; changes in 
urine after administration of, 466; clas- 
sification of, 462; definition of, 459; 
"normal," 313; odor of, 31; suicide by, 
505; symptoms observed after admin- 
istration of, 463 

Poley oil, toxicology of, 465 

Poliomyelitis, 388; acute anterior, 262; 
chronic anterior, 257, 265 

Polycythemia, 129, 138 

Polydactylism, 3 

Polygnathus, 77 

Polymelus, 77 

Polypi, 99, 128, 148, 183, 203, 220 

Polyserositis, 102, 223 

Pons Varolii, examination of, 16, 247, 483, 
Figs. 143=149 

"Porcelain" liver and spleen, 102, 223 

Porencephalus (porencephaly), 260, 266 

Pork, see Pig 

Portal vessels, 16, 17, 154, 204, 205, 401, 
413, Figs. 121, 122 

Post, see Postmortem 

Posterior sclerosis, see Ataxia, locomotor 

Postmortem (or post-mortem) , see Exami- 
nation of, under the several entries, 
for the post-mortem examination of the 
various parts and organs and the va- 
rious illustrations bearing upon this 
subject; Anatomical Boards and, 5; 
anatomy studied at, 3; Army and, 43; 
assistants at, 6; at hospital, 9, 11; at 
morgue, 9, 11; at place where carcass 
is found, 408; at private house, 9 
at undertaker's, 9; bacteriologic, 392 
blood-color scale for, 126, Plate three 
Boards of Health and, 4; books for re- 
cording, 18, 19, 25; books on, xxxi, p. 
508 (see also second edition of this 
work) ; cadaver improved in appearance 
by, 9, 290; care in making, 2; cause of 
death determined by, 2, 32, 447, xxx, 
p. 491; cleanliness at, 10; closure of 
body in, xx, p. 298; comparative, xxv, 
p. 407; compulsory, 4; consent for, 3, 
290; contraction of infectious diseases 
at, 48; decomposed bodies and, 57, 480; 
defendant represented at, 462; defini- 
tion of, 2; determination of viability of 
child by, 293, 443, 444, 488; disinfection 
after, 47; dress of operator at, 10, 408; 
electrocution and, 7, 74, 454, 506; ex- 
amination of body before, v, p. 53; ex- 
citability of heart at, 444; exhumed, 
462, 463; experimental, 392; final report 
of, 489; foetus expelled from mother at, 
53; frozen bodies and, 302, 305, 481; 
general considerations on, i, p. 1; guests 
at, 7; historical considerations of, 1; 
illumination at, 12, 481; immunity de- 
rived from constant inoculation at, 



Postmortem {continued) 
50; importance of, 2; in America, 1; 
in England, 1; in France, 17, Figs. 
133, 134; in Germany, 8, xxix, p. 479; 
in Massachusetts, 1; in New York, 1, 5; 
in Pennsylvania, 1, 5; in poisoning, 
442; in Vienna, 7; infections from, 
48; instruments for, iii, p. 34, 407, 480; 
instruments for Army, 43; instruments 
for Navy, 43; insurance companies and, 
4, 5; interns and, 4, 6, 30; interval to 
elapse before making, 7, 480; labora- 
tory, upon animals, 407; law permit- 
ting, 5; legal aspects of, 1, 3, 4, 5, 6; 
light at, 9, 12, 481; literature on (see 
also second edition of this work), xxxi, 
p. 508; Marine-Hospital Service and, 
23; medicolegal, 2, 7, 16, 46, 440; mi- 
croscopic examinations at, 41, 42, 268, 
370, 481; multiple, 462; Navy and, 22, 
43; note-taking at, 23; nurse at, 7; ob- 
jects of, 2; odor at, 11, 302; of Bishop, 
7; of Brooks, Phillips, 5; of Jones, 
Admiral Paul, 62; of McKinley, 6; of 
Rameses II, 62; on animals, 392; on 
birds, 429; on calves, 423; on cats, 
407, 408, 427; on children, xxviii, p. 
289; on cows, 407; on dogs, 408, 427, 
Figs. 199, 200; on goats, 407, 425; on 
guinea-pigs, 407; on horses, 407, 408, 
410, Figs. 189=193; on infants, 443; 
on lower animals, xxv, p. 407; on mice, 
407; on new-born, xviii, 289; on plants, 
xxvi, p. 432; on rabbits, 407; on rats, 
407; on ruminants, 423, Figs. 194=197; 
on sheep, 407, 425, 427, 429, Fig. 198; 
on snakes, 407; on swine, 408, 426; 
operations at, 3; order of examination 
at, ii, p. 14, xxv, 429, xxix, p. 481; per- 
mission to perform, 3, 4; per rectum, 
Figs. 106=114; per vaginam, Figs. 
106=114; persons present at, 6; place 
at which made, 8, 408, 481; portable 
table for, 9, Fig. 1 ; preparation for, 9; 
protocol of, 489; Prussian regulations 
for the performance of medicolegal, 
xxix, p. 479; purpose of, 2; record 
books for, 19; record books for, on 
animals, 249; records of, ii, p. 14; 
references on (see also the second edi- 
tion of this work), xxxi, p. 508; repeti- 
tion of, 8; report of, 490; resident phy- 
sicians making, 6; restricted, xix, p. 295; 
rheumatism from making, 13; room 
for, 11; rules for performing, 14; scales 
at, 11, 38; scheme for record of, in 
lower animals, 429; smoking at, 7; so- 
cieties for promoting, 5; specimens se- 
cured from, 6; stool for instruments at, 
13; study of anatomy at, 3; study of 
physiologic structures in, 3; substitute 
for daylight at, 9; substitutes in, 480; 
suggestions at, 8; surgical operations 



38 



INDEX 



Postmortem (continued) 
at, 3; synonyms of, 2; table for, 9, 
12, 40, Figs. 1, 3, 4, 10, 11; teaching 
of technic at, xxvii, p. 434; teeth, re- 
moval of, at, 6; temperature of body 
at, 7; those present at, 6; time after 
death before making, 7, 480; time for 
performance of, 7, 480; time of com- 
pleting, 8; to be made before the body 
is dressed, 9; toxicologic, 46, 442, 487; 
transportation of corpses for, 481; un- 
dertaker at, 4, 7, 9, 10; veterinary, 
407 

Post-mortem lividity, see Lividity, ca- 
daveric; rigidity, 4, 6, 14, 30, 59, 311, 
331, 334, 409, 444, 482; wounds, iv, p. 
45 

Post-partum hemorrhage, 142 

Potassium, toxicology of, 452 

Potassium bichromate as a fixing fluid, 
245, 252; toxicology of, 9, 465, 467, 
470 

Potassium binoxalate, toxicologv of, 466, 
468 

Potassium cantharidate, toxicology of, 
466, 468 

Potassium chlorate, toxicology of, 58, 
69, 213, 465, 467, 477 

Potassium chromate, toxicology of, 461 

Potassium cyanid, toxicology of, 461, 463, 
473 

Potassium iodid, toxicology of, 71 

Potassium permanganate, use of, 47 

Potato bug, distribution of, 432 

Pott's disease, 81, 99, 105, 186, 208, 253, 
493 

Poultice, flaxseed, 51 

Poupart's ligament, 98 

Powder, talcum, 46 

Powder markings, 63, 449, Plate six 

Pregnancy (the German law accepts a 
duration of 302 days as the maximum. 
See also Extra-uterine Pregnancy), 
81, 130, 503 

Premature interments, 53 

Prepuce, examination of, in animals, 408, 
430 

Preservation of body, xx, p. 298; of 
clothing, 63; of tissues for macro- 
scopic and microscopic study, xxii, p. 
368 

Priapism, 468 

Probes, 38 

Proctitis, 319 

Progeria (see also Ateleiosis), 258 

Prognathous skull, 398 

Prosopothoracopagus, 77 

Prostate, diseases of, 3, 215, 222, 319, 
348, 502; examination of, 15, 17, 196, 
406, 486 

Prostatitis, 319 

Prostration, 506 

Proteus, see Bacterium vulgare 



Protocol of postmortem, 489 

Protozoa of smallpox, 333 

Provisional diagnosis, 440; opinion of ob- 

ducent, 431, 489 
Prurigo, 72 
Pruritis, 73 
Prussian blue for injecting, 380; for 

testing presence of iron, 206 
Prussian regulations for medicolegal au- 
topsies, xxix, p. 479 
Psammocarcinoma of ovary, 219 
Psammoma, see Acervuloma 
Pseudoarthrosis, 280 
Pseudencephalus, 76 
Pseudohypertrophic muscular atrophy. 

207; paralysis, 92 
Pseudoleukemia, 138 
Psilosis, 334 
Psittacosis, 128 
Psoas muscles, 16, 208, 413 
Psoriasis, 71, 72 
Psorospermosis, 365 
Ptomaine poisoning, 463, 477 
Ptosis, 83, 464 
Puerperal diseases, 49, 73, 261, 264, 293, 

326, 356, 503 
Pulex cheopsis, 326, 358; P. irritans, 

358; P. penetrans, 358 
Pulmonary vessels, diseases of, 136, 142, 

163, 234, 499; examination of, 17, 114, 

115, 117, 118, 122, 400, 485, Figs. 75, 

80, 83, 88, 167 
Pulse in poisoning, 466 
Puncture, fatal exploratory, 74; Quincke's 

lumbar, 3, 352 
Pupillary membrane, 445, 488 
Pupils, 54, 56, 84, 464 
Purpura, 71, 72, 73, 99, 139, 140, 142, 163, 

322, 331, 355, 492, 503 
Pustule, 72, 308, 464; malignant, 309 
Putrefaction, 57, 128, 134, 356, 482 
Pyaemia, 49, 134, 135, 139, 145, 202, 229, 

326, 329 
Pyelitis, 214, 319 
Pyelonephritis, 214, 355 
Pygopagus, 76 

Pylorus, 59, 199, 201, Fig. 122 
Pyopneumothorax, 91 
Pyosalpinx, 218 
Pyosepticsemia, 229 
Pyothorax, 169 
Pyramidon, toxicology of, 467 
Pyrogallic acid, toxicology of, 463 
Pyrogallol, toxicology of , 465, 467 



Question, medicolegal, 449 
Quillaja bark, toxicology of, 464 
Quincke's lumbar puncture, 3, 352 
Quinine, toxicology of, 71, 464, 467; use 

of, in cellulitis, 51 
Quinquaud's sign, 278 



INDEX 



539 



Rabbit, Coccidia of, 366;inoculation of, 
390, Figs. 185, 186; postmortem on, 
407, Fig. 188 
Rabic tubercle, 321 
Rabies, 267, 320, 388, 407, 461, 492 
Race, determination of, 67 
Racemose aneurism, 152 
Racial characteristics, 64, 67 
Radio-activity, 443 
Ranunculus acris, toxicology of, 464; 

R. sceleratus, toxicology of, 464 
Rape, 63, 221, 459 
Raspatory, 38, 39, Fig. 48 
Rat as disseminator of bubonic plague, 
407; postmortem on, 407; Trypano- 
soma of, 367 
Ray-fungus, 306 

Raynaud's disease, 129, 265, 465 
Razor, 35, 480 

Reaction, agglutinative, 128; for diag- 
nosis of human blood, 323 
Receptaculum chyli, examination of, 208 
von Recklinghausen's disease (hsemo- 

chromatosis), 267 
Records, post-mortem, ii, p. 14 
Rectum, diseases of, 79, 155, 294, 494; 
examination of, 15, 17, 194, 195, 295, 
338, 361, 486, 494; examination of, in 
animals, 412, 413, 416, 420, 426, 428, 
430, Figs. 189, 198 
Red, trypan, 367 

References to literature on postmortems 
(see also the second edition of this 
book), xxxi, p. 508 
Refrigerator box, 11, Figs. 5=8, 181, 182 
Regional landmarks, 26, 509 
Regulations, Prussian, for performance of 
medicolegal postmortems, xxix, p. 497 
Regurgitation, tricuspid, 148 
Relapsing fever, 135, 283, 329, 491 
Renal, see Kidney 
Report, post-mortem, 490 
Reptiles, postmortems on, 407 
Resident physicians and postmortems, 

4, 6, 30 
Resorcin-phthalein test, 55 
Respiration, absence of, in child, 487; 

tests for cessation of, 54 
Respiratory apparatus, diseases of, iv, 

p. 156, 321, 338, 344, 498, 499 
"Ptest" bacillus, 344 
Restoration and preservation of body, 

xx, p. 298 
Restricted post-mortem examinations, 

xix, p. 295 
Retina, 85 
Retinitis, 336 

Retroperitoneal glands, examination of, 16 
Retropharyngeal abscess, 310, 314, 332 
Reversed peristalsis, 182 
Rhabdomyoma, 148, 214, 221, 222 



Rhabdonema intestinale, 363 

Rhachioschisis, 260 

Rhachiotome, Luer's, 35, 254, 483 

Rhachipagus, 77 

Rhachitis, see Rickets 

Rheumatism, 13, 71, 110, 146, 151, 283, 

324, 330, 332, 388, 494, 495 
Rhinitis, 156, 157, 159 
Rhinoliths, 156 
Rhinoscleroma, 156 
Rhubarb root, toxicology of, 467 
Rhus toxicodendron, toxicology of, 464 
Ribs, diseases of, 78, 81, 105, 111, 308; 

examination of, 105, Figs. 63=66 
Rice bodies, 275, 287, 351 _ 
"Rice-water" discharges in cholera, 311, 

312 
Ricin, toxicology of, 463, 477 
Rickets, 80, 81, 105, 106, 141, 158, 163, 

226, 283, 286 
"Rider's" bones, 93 
Rigidity, post-mortem (cadaveric), 14, 

30, 59, 60, 311, 331, 334, 409, 443, 482, 

485 
Rigor mortis, see Rigidity, post-mortem 
Ring worm, 72 
Ripault's test, 56 
Robin's injecting fluid, 380 
Rocks, natural selection in, 432 
Rokitansky, 8, 15, 223 
Rontgen rays, see X-rays 
Rose rash, 388 
Rotheln, 156, 331 
Rougemont, Philip, 1 
Rough-on-rats, 471 

Round ligaments, examination of, 204 
Round worms, 361 
Rubber bag, 42; catheter, 42; coat, 47; 

finger-stalls, 47; gloves, 40, 42, 46, Figs. 

97, 104, 123; sheeting, 42 
Rubella, 331 
Rubeola, 324 
Rue, toxicology of, 466 
Ruler, 65 
Ruminants, postmortem on, 408, 423, 

Figs. 194 = 197 
Rupia, 336 
Rupture of aneurism, 106, 153, 200; of 

bladder, 216; of diaphragm, 208; of 

Fallopian tubes, 218; of heart, 144; of 

liver, 223; of spleen, 176; of stomach, 

107; of tubal pregnancy, 129; of uterus, 

220 
Rustan, weight of brain of, 399 
Ruysch, van Neck's painting of, Fig. 165 



Sabina, toxicology of, 466 

Sacrum, 68 

Sago spleen, 178 

St. Vitus's dance, see Chorea 

Salicylic preparations, toxicology of, 464 



54Q 



INDEX 



Saline injections, 74 

Salivary calculi, 274 

Salivary glands, diseases of, 274, 346; 
examination of, 15, 16, 402, 430, 485 

Salivation, 465 

Salmon, cancer of, 108 

Salol forming enteroliths, 183 

Salpingitis, 218, 319 

Salt water, drowning in, 458 

Salve, antiseptic, 45 

San Jose scale, 432 

Sand for filling in cavities, 41; false, in 
intestines, 183 

Sand-flea, 358 

Santonica seeds, toxicology of, 467 

Santonin, toxicology of, 463, 467 

Saponiferous substances, toxicology of, 467 

Saponine, toxicology of, 465 

Sapraemia, 135 

Saprophytes, 50 

Sarcinae, 387 

Sarcoma (adenocystic, alveolar, angio-, 
chondro-, fibro-, giant-celled, lympho-, 
melano-, medullary, myeloid, myxo-, 
osteo-, perithelial, round-celled, spindle- 
celled, telangiectatic, tubular, etc.), 
70, 106, 154, 217, Plate four; of adrenals, 
192; of appendix, 185; of bladder, 216; 
of bone, 288; of brain, 267; of breast, 
70; of choroid, 85; of ciliary body, 85; of 
dura mater, 230; of eye, 33, 230; of 
heart, 111, 148; of intestines, 183; of 
iris, 85; of kidney, 214; of larynx, 158; 
of liver, 33, 230; of lungs, 169; of 
lymph-gland, 207; of mediastinum, 106; 
of nasal passages, 156; of neck, 153; 
of ovaries, 219; of penis, 230; of peri- 
cardium, 111; of pituitary body, 258; 
of pleura, 170; of skin, 73, 230; of 
spleen, 178; of testicles, 222; of thyroid 
gland, 108; of tonsils, 158; of vagina, 
221 

Sarcoptes scabiei, 358 

Satchel, contents of, for post-mortem 
work, 41 

Satterthwaite's clamp, 38, Fig. 42 

Saturnism, see Lead, toxicology of 

Sausage poisoning, 464, 465 

Saw, 35, 36, 42, 43, 103, 254, 408, 480, 
Figs. 21=26, 163 

Sawdust in preservation of body, 41 

Scabies, 72 

Scalds, 454, 506 

Scale, 11, 38, 42, 480, Figs. 5, 6, 7, 8; 
moisture, 127, Plate three; post-mor- 
tem blood-color, 126, Plate three; Tall- 
qvist's blood-color, 126 

Scalp, examination of, 16, 235 

Scalpels, 35, 42, 43, 242, 368, 408, 480, 
Fig. 21 

Scar, 15, 73, 74, 228, 336, 481 

Scarlatina (scarlet fever), 72, 93, 149, 156, 
202, 226, 283, 324, 331, 388, 466. 491 



Scharlach R, 380 

Schistosoma Cattoi, 363; S. hcematobium, 
364; S. japonicum, 363 

Schultze's clearing method, 380 

Schweinfurth green, toxicology of, 465 

Scilla, toxicology of, 466 

Scissors, 37, 42, 43, 241, 243, 408, 480, 
Figs. 28=32 

Sclera, 84 

Sclerema, 505 

Scleroderma, 73, 313, 332 

Sclerose en plaques, 265 

Sclerosis, amyotrophic lateral, 257; dis- 
seminated, 324; gummatous, 337; mul- 
tiple, 361; of arteries, 231, 232, 233; of 
brain, 265; of spinal cord, 265; pos- 
terior, see Ataxia, locomotor; primary 
lateral, 265 

Scolices, 360 

Scoliosis, 81, 208, 283 

Scopolamine, toxicology of, 464, 465, 466, 
468 

Scorpion, poison of, 463 

Scrapings, method of examining, 122, 
368 

Scrofula, 72, 326, 493 

Scrotum, diseases of, 78, 155; examina- 
tion of, 15, 419, Figs. 117=119; ex- 
amination of, in animals, 408, 409, 430, 
488 

Scurvy, 71, 72, 130, 140, 141, 163, 495 

Sealing-wax, 40, 42 

Seat-worms, 183, 361 

Sebaceous cysts, 82 

Seborrhcea, 72 

Secondary anaemia, 129 

Sectio anatomica, see Postmortem; S. ca- 
daveris, see Postmortem 

Section, see Postmortem 

Section-knife, 34, Figs. 14 = 16 

Sections, frozen, preparation of, 370; 
microscopic, preparation for, 320, 371 

Segmentation of heart, 143 

Selenium, toxicology of, 468 

Semen, 63, 133, 459 

Semilunar ganglia, 15, 192; valve, 126, 
144 

Seminal vesicles, examination of, 15, 196, 
197, 406, 486, Fig. 120 

Senile changes, 144, 149, 505 

Senna leaves, toxicology of, 467 

Sepsis and Septicaemia, 48, 49, 57, 119, 
135, 139, 145, 264, 326, 329, 492, 503 

Septum of heart, 114,' 118, 126; of nose, 
156; of pancreas, 230 

Serous membranes, appearance of, 96, 
109 

Serum (antianthrax, antidiphtheritic, an- 
tiplague, antistreptococcic, antitetanus, 
etc.), 140 

Sewing up of body, 301, Figs. 175, 176 

Sex, 64, 67, 481 

Sheaths, diseases of, 286 



INDEX 



541 



Sheep, diseases of, 360, 363; postmortem 
on, 407, 425, 427, Fig. 198 

Sheeting, rubber, 42 

Shiga, bacillus of, 314 

Shock, death due to, 32 

Siderosis, 168 

Sigmoid flexure, diseases of, 101, 173 

Signs of death, 53 

Silicosis, 168 

Silk, oiled, 42 

Silver nitrate, toxicology of, 247, 465, 
477; uses of, 51, 71, 369 

Simple anaemia, 129 

Singers' nodes, 158 

Sinus, longitudinal, 16; of Valsalva, aneu- 
risms of, 146, 154 

Sinuses, accessory, exposure of, in animals, 
423 

Sitotoxismus, 460 

Situs inversus, 126 

Size, how estimated, 27, 431, Plate two 

Skatol, odor of, 32 

Skeleton, 66, 396 

Skiagraphs, see X-rays 

Skin and its appendages, diseases of, 33, 
45, 68, 69, 71, 72, 73, 75, 124, 130, 135, 
137, 147, 230, 324, 330, 331, 333, 357, 
366, 464, 504; examination of, 15, 70, 
430 

Skin flap, Fig. 71 

Skull, diseases of, xiii, p. 235, 339, 340; 
examination of, xiii, p. 235, Figs. 126= 
140; fracture of, 1, 236, 244, 449; 
restoration of, 299, Figs. 177, 178; 
shapes of, 397 

Skullcap, see Calvarium 

Sleeping-sickness, 366 

Slee's method of fixing calvarium, 299, 
Fig. 177 

Slide, microscopic, 24, 384 

Slide-box, 385 

Small intestine, see Intestines 

Smallpox, 31, 33, 48, 56, 71, 72, 93, 156, 
157, 283, 326, 333, 334. 388, 491 

" Smear" preparations, 383, 389 

Smegma bacillus, 348 

Smell, sense of, 257 

Smokeless powder, 449, Plate six 

Smoking, prohibition of, at postmortem, 7 

Snake, postmortem on, 407 

Snake venom, toxicology of, 57, 463, 478 

Soap, 42, 47 

Soapstone for rubber gloves, 40, 46 

Sodium acetate, uses of, 252 

Sodium bisulphite, 47 

Sodmm chlorid, physiologic solution of, 
368; use of, 252 

Sodium hydrate, toxicology of, 462, 470 

Sodium nitrite, toxicology of, 465, 467 

Sodium urate, 141 

Soft chancre, 493 

Softening of brain, 261, 263, 496 

Solanine, toxicology of. 467 



Solanus pseudocapsicum, toxicology of, 
461 

Somatic nutrition, 68 

Sounds, 480 

Spanish fly, see Cantharides 

Specific gravity, method of determining, 
27 

Specimens, preservation of, 6, 40, 41, 42, 
xxii, p. 368 

Spectroscope, pocket, 126 

Spermatic cord, diseases of, 155, 222; 
examination of, 15, 16, 44, 198, Figs. 
117=120, 122 

Spermatozoa, 54, 133, 221, 459 

Sphenocephaly skull, 398 

Spina bifida, 77, 266 

Spinal column, diseases of, 283, 310; 
examination of, 16, xiv, p. 253, 427, 
483, Figs. 153=158, 169 

Spinal cord, diseases of, 136, 215, 255, 256 
xv, p. 257, 258, 261, 262, 264, 267, 283, 
310, 321, 332, 359, 495; examination 
of, 16, 243, xiv, p. 253, 254, 292, 483, 
Figs. 152=159, 169; examination of, 
in animals, 423, 430; hardening of, 255; 
measurements of, 400; nerves of, 16; 
weight of, 394, 400 

Spinal ganglia, examination of, 258, 341 

Spinal membranes, hemorrhage of, 269 

Spine, typhoid, 355 

Spirals, Curschmann's, 159 

Spirochetes Obermeieri, 135, 329, 387; S. 
pallida, 335, 387; *S. refringens, 387 

Splanchnic nerves, 15 

Spleen, absence of, 176; accessory, 101, 
176; actinomycosis of, 308; amyloid 
degeneration of, 178; angioma of, 178; 
anthracosis of, 169; anthrax of, 310; 
atrophy of, 175, 224; blood-vessels oi, 
15; cancer of, 178, 201; capsule of, 15; 
chronic capsulitis of, 227; coal-dust in, 
176; Coccidium of, 366; color of, 176; 
congestion of, 160; diseases of, 175, 323, 
501; Echinococci of, 31, 178; embolism 
of, 147; examination of , 15, 17, 175, 295, 
486; examination of, in animals, 393, 
413, 414, 415, 416, 417, 426, 430, Fig. 
191; follicles of, 15; gumma of, 178; 
in acute yellow atrophy, 224; in Addi- 
son's disease, 191; in cholera, 312; in 
cirrhosis of liver, 227; in diabetes melli- 
tus, 234; in dysentery, 316; in erysipe- 
las, 317; in Hodgkin's disease, 139; 
in leprosy, 323; in leucocythaemia, 137; 
in malaria, 175, 365; in Malta fever, 
323; in plague, 326, 327; in pneumonia, 
329; in relapsing fever, 330; in scar- 
let fever, 332; in smallpox, 334; in 
typhoid fever, 353; infarcts of, 177; 
leukaemia of, 177; leucocythaemic, 137; 
measurements of, 404; of babe, anat- 
omy of, 290; Pentastomum denticu- 
latum of, 178; pulp of, 15; puncture of, 



542 



INDEX 



Spleen (continued) 

367; rupture of, 137, 176, 330; sago, 
178; sarcoma of, 178; softening of, 176; 
supernumerary, 100; syphilis of, 340; 
trabecular of, 15; tuberculosis of, 177, 
347, 349; tumors of, 130; typhoid, 355; 
volume of, 404; wandering, 176; weight 
of, 175, 394, 396, 404 

Splenic artery, aneurism of, 154, 176; tu- 
mor, 177 

Splenitis, 177 

Splenization, 137 

Splenomegalies, 367 

Spondylitis deformans, 277 

Spondylosis ("poker back," spondylose 
rhizomelique) , reference on, 288 

Sponges, 10, 40, 42 

Spores, bacterial, longevity of, 308, 393 

Sporozoits, 364 

Spots, parchment-like, 75; Tardieu's, 113, 
144 

Spotted fever, 264, 310 

Sprains, 506 

Spreads, preparation of, 384 

Sprue, 334 

Sputum, 159 

Squill, toxicology of, 463 

"Stab" cultures, 389; in making cultures 
of anaerobes, 389 

Stab-wounds, 106 

Stains on clothing, 63 

Staphylococcus, 50, 174, 327, 330, 387 

Starvation, 129, 130, 456 

Status lymphaticus, 294 

Steatoma, 73 

Steel tape measure, 42 

Stegomyia fasciata, 357 

Stenosis, 148, 151; of aorta, 147, 148; of 
blood-vessels of heart, 126; of bronchi, 
160; of larynx, 109, 158; of mitral 
valve, 118, 144, 147; of pylorus, 201; 
of trachea, 109, 124; of ureters, 215; 
of uterus, 219 

Sterilized instruments, 34, 46, 52 

Sternum, diseases of, 105, 308; examina- 
tion of, 103, 104, 105, 484, Figs. 58=61, 
68=70 

Stillbirths, 507 

Stomach, abrasions of, 199; abscesses of, 
202, 308; atony of walls of, 201; bile 
in, 200; cancer of, 199, 201; capacity of, 
101; cicatrices of, 203; contents of, 41, 
199, 460, 487; dilatation of, 201; Dip- 
teral in, 200; diseases of, 321, 322, 494, 
500; diverticula of, 198; effect of poi- 
sons on, 461; epithelioma of, 201; ex- 
amination of, 16, 17, 46. 100, 101, 199, 
290, 295, 486, 487, Figs. 72, 75, 121 - 
123, 164; examination of, in animals, 
413, 414, 415, 416, 417, 426, 428, 430, 
Figs. 191, 198; foreign bodies in, 200; 
gall-stones in, 200; hour-glass contract- 
ure of, 100, 201; hemorrhage from. 



Stomach (continued) 

142, 199, 202, 203; in actinomycosis, 
308; in anthrax, 203; in beriberi, 310; 
in cholera Asiatica, 312; in cirrhosis of 
liver, 227; in favus, 203; in progressive 
pernicious anaemia, 136; in relapsing 
fever, 330; in thrush, 203, 341; in 
tuberculosis, 346; infiltration of, 202; 
inflammation of, 202; injuries to, 202; 
measurements of, 100, 402; mucous 
membrane of, 16; muscularis of, 16; 
mucus of, 203; Oxyuris vermicularis 
of, 200; polypi of, 203; position of, in 
babe, 100; psychic secretion of, 182; 
rupture of , 101; submucosa of, 16; Tri- 
china? spiralis of, 361; ulcer of, 98, 199, 
201,500; weight of, 402 

Stomach pump, 39 

Stomatitis, 324 

Stomatitis aphthosa epizootica, 317 

Stone formations, see Calculi 

Strabismus, 83 

Stramonium, toxicology of, 456, 464 

Strangulation, 124, 456, 486, 505 

Strangury, 468 

Streptococcus, 50, 174, 316, 327, 333, 387 

Streptothrix, 306, 308, 387 

Stricture, 33, 124, 193, 200, 201 

"Stroke" culture, 389 

Strongylus annatus, 153; S. duodenale, 
see Anchylostoma duodenale; S. gi- 
gas, 166, 212; S. subtilis, 363 

Strop, 39, Fig. 21 

Strophanthus, toxicology of, 466 

Struma aneurysmatica, 162; S. varicosa, 
162 

Strumipriva, cachexia, 107 

Strychnine, toxicology of, 59, 60, 193, 
461, 463, 468, 478 

Subclavian vein, 15 

Subcutaneous inoculation of animals, 391, 
Figs. 184-186 

Subdiaphragmatic abscesses, 172, 204 

Sublingual glands, 17 

Submaxillary glands, 402 

Submersion, accidental, death by, 506 

Subpericardial ecchymoses, 113; fat, 113 

Subphrenic abscesses, 172, 204 

Sucking gland, 75 

Sudan III, 371, 380 

Sudden death, 33, 503, 507 

Suffocation, 60, 109, 113, 145, 158, 456 

Suffusions, hemorrhagic, 142 

Suggillations, 142 

Suicide, 449, 505, 506 

Sulphid of ammonium, 41 

Sulphonal, toxicology of, 463, 467 

Sulphur balls, 306 

Sulphur dioxid, toxicology of, 462 

Sulphuretted hydrogen, odor of, 32 

Sulphuric acid, toxicology of, 32, 461, 462, 
467, 468 

Summer diarrhoea of children, 315 



INDEX 



543 



Sunstroke, 237, 456 

Superior vena cava, measurements of, 401 

Supernumerary, see Accessory under 
the names of the various organs 

Supplies, bacteriologic, 41; ehemic, 41; 
microscopic, 41 

Suppuration, 97, 135, 154 

Suprarenals, see Adrenals 

Surgery, practice of, at postmortem, 3 

Surgical instruments left in abdominal 
cavity, 99 

Surra, 366 

Suspended animation, 53 

Suspensory ligament of liver, 99 

Sutures, cranial, 67 

Suturing of heart muscle, 112 

Sweat-glands, hemorrhage of, 142 

Sweating (miliary) fever, 492 

Swelling, cloudy, 324, 372 

Swine, see Pig 

Sydenham's chorea, see Chorea 

Symbiosis, 231, 388 

Symelus, 76 

Sympathetics, 16, 33, 125, 324 

Symphysis menti, 123 

Symptomatic anaemia, 129 

Symptoms observed after the adminis- 
tration of the more common poisons, 463 

Syncephalus, 77 

Syncope, fatal, 32 

Syncytioma malignum, 219 

Syndesmosis, 280 

Synonyms of causes of death, xxx, p. 491; 
of '' postmortem," 2 

Synostosis, 80, 236, 283 

Synovial membrane, diseases of, 139 

Syphilis, 48, 71, 72, 78, 81, 130, 145, 156, 
261, 326, 327, 335, 493; congenital, 
109, 130, 292, 339; in aneurism, 154; in 
locomotor ataxia, 258; of anus, 336, 
338; of arteries, 152, 337; of bones, 
275, 278, 336, 337, 339, 340; of brain, 
285, 337; of bronchi, 338; of central 
nervous system, 337; of circulatory sys- 
tem, 337; of ears, 340; of eyes, 340; of 
fingers, 336; of gastro-intestinal tract, 
337; of hair, 336; of heart, 148, 337; 
of intestines, 338; of joints, 278, 336, 
339; of kidneys, 338; of larynx, 158, 
336; of liver, 224, 226, 228, 230, 335, 
338, 340; of lungs, 163, 339; of lymph- 
glands, 207; of lymph- vessels, 155, 207; 
of nasal passages, 156; of nervous sys- 
tem, 267, 337; of nose, 156, 339; of 
oesophagus, 337; of palate, 336; of pan- 
creas, 231; of pericardium, 111; of peri- 
osteum, 336; of penis, 335; of pharynx, 
338; of skin, 336, 337; of spinal cord, 
337; of spleen, 175, 178, 340; of testis, 
383; of tongue, 123, 335; of tonsils, 
158, 336; of trachea, 124; of uterus, 
220; of veins, 155; of vulva, 336; or- 
ganisms of, 335, 369; rash of, 336 



I Syringes, 38, 390 

! Syringomyelia, 257, 261, 266 



T incision, 273 

Tabes dorsalis, see Ataxia, locomotor; 
T. mesenterica, 351 

Table, postmortem, 11, 40, Figs. 3, 4, 10, 
1 1 ; portable, 9, Fig. 1 

Table of approximate weights of internal 
organs, 396; of author's, 779 Coroner's 
cases, 451; of changes effected in urine 
by poisons and medicines, 467; of co- 
efficients for determining height from 
the length of long bones, 66; of dif- 
ferences between croupous and catarrhal 
pneumonia, 167; of differences between 
tuberculous and typhoid ulcers, 354; 
of poisons, 463; of symptoms observed 
in administration of poisons, 462, 463 

Tcenia bothriocephalus latus, 360; T. cu- 
cumerina, 361; T. echinococcus, 360; 
T. fiavopunctata, 360; T. madagascari- 
ensis, 361; T. mediocanellatce, 182; T. 
nana, 183, 361; T. pisiformis, 361; T. 
saginata, 359, 361; T. solium, 359, 360 

Taguchi, weight of brain of, 399 

Tail, examination of, 420 

Talcum powder, 46 

Talipes calcaneus, 283; T. cavus, 283; T. 
equinus, 261, 283; T. planus, 283; T. 
valgus, 283; T. varus, 283 

Tallqvist's blood-color scale, 126 

Tannin, toxicology of, 478 

Tape measure, 38, 42, 65, Fig. 21 

Tape-worm, see Tamia 

Tar, toxicology of, 464 

Tattoo marks, 69, 482 

TC, 343 

"Tea" cigarettes, 452 

Teaching of post-mortem technic, xxvii, 
p. 434 

Technic, see Examination of, under the 
various parts and organs 

Teeth, diseases of, 87, 88, 156, 293; ex- 
amination of, 6, 15, 87, 482, Figs. 173, 
174; examination of, in animals, 430; 
Hutchinson's, 88, 339, 340 

Tellurium, toxicology of, 32, 466, 468 

Temperature, fall of, after death, 56; of 
animals, how taken, 390, Fig. 183; 
rise of, after death, 7 

Tenaculum, 38 

Tendons, 16, 286, 430 

Tenosynovitis, 286 

Terata anadidyma, 77; T. anakatadidy- 
ma, 77; T. katadidyma, 76 

Teratoma of pleura, 170 

Test, antiserum, 132, 396; CattelPs, 465; 
Gmelin's, 134; Icard's, 55; Magnus's. 
55; Ripault's, 56; Widal's, 134, 181, 
353, 354; Winslow's, 54 



544 



INDEX 



Testicles, diseases of, 78, 222, 323, 325, 
338, 348, 353, 366, 396, 405; examina- 
tion of, 15, 17, 196, 419, 486, 488, Figs. 
117=119 

Testimony, expert, 437 

Testis, see Testicles 

Tests of death, 55 

Tetanus, 48, 52, 56, 59, 93, 128, 135, 340, 
341, 496 

Tetanus neonatorum, 341 

Tetranol, toxicology of, 467 

TGL, 344 

Thawing of frozen bodies, 305, 481 

Thermocautery, Paquelin, 41 

Thigh, disease of, 155 

Thiosulphate of sodium, toxicology of, 466 

Thoracic and abdominal organs, removal 
of, in one piece, 125, Fig. 94 

Thoracic aorta, aneurism of, 154 

Thoracic cavity, examination of, 44, vii, p. 
103, 120, 208, 289, 401, 482, 484, Figs. 
55, 72, 94, 164, 165, 167; examina- 
tion of, in animals, 410, 417, 418; in- 
jection of embalming fluid into, 103 

Thoracic duct, 15, 16, 17 

Thread, 40, 43; poisoning from, 452 

Thread-worms (Oxyuris), 361 

"Three color" printing, 28, Plate three 

Thrombo-arteritis, 151 

Thrombophlebitis, 124, 229 

Thrombosis, 100, 143, 151, 152, 154, 163, 
244, 322, 498 

Thrombus, 33, 128, 129, 136, 144, 151, 152 

Throttling and hanging, differentiation 
of, 457 

Thrush, 124, 203, 220, 341 

Thuja, toxicology of, 466 

Thymol, toxicology of, 467 

Thymus gland, diseases of, 107, 137, 162, 
191, 257, 294; examination of, 15, 17, 
443, 485, 488, Plate one, Figs. 72, 164; 
measurements of, 107, 405; weight of, 
106, 394, 396, 405 

Thyroglossal duct, 108, 120 

Thyroid gland, arsenic in, 471; dimen- 
sions of, 405; diseases of, 47, 74, 75, 
108, 161, 162, 257, 260, 498; examina- 
tion of, 15, 17, 107, 485; examination 
of, in animals, 418, 430; measurement 
of, 405; weight of, 394, 405 

Thyroiditis, 107 

Tibial nerves, removal of, 256 

Ticks, 306, 358 

Time after death before making autopsy, 
7, 480; for body to skeletonize, 68; for 
weighing organs, 394 

Tin, toxicology of, 473 

Tinea favus, 504; T. sycosis, 72; T. ton- 
surans (Trichophyton) , 504 

Tissue, cellular, diseases of, 504 

Toadstools, toxicology of, 128, 460, 466, 
477 

Toilet of hair, 235, Figs. 127, 128 



Toluidin, toxicology of, 465 

Toluylendiamin, toxicology of, 467 

Tongue, diseases of, 77, 123, 307, 325, 341; 
examination of, 15, 17, 44, 122, 123, 
482, 485, Figs. 90=93; examination of, 
in animals, 430; hairy, 77, 

Tonsils, diseases of, 158, 331, 336, 346; 
examination of, 15, 17, 123, 485 

Tophi, 82, 141 

Tourgenieff , weight of brain of, 399 

Tow for packing large cavities, 41 

Toxaemia, 329 

Toxicology, general considerations of, 459 

Toxin of diphtheria, 313; of pysemia, 135; 
of tetanus, 463 

Toxon of diphtheria, 313 

Trabeculse of heart, 15 

Trachea, diseases of, 109, 124, 159, 161, 
163, 321, 334; examination of, 15, 17, 
122, 123, 124, 289, 485, 488, Fig. 90; 
examination of, in animals, 416, 418, 
428, 430 

Trachoma (contagious granular lids, per- 
haps carried by flies), 497 

Trance, cases of, 53 

Transfusion, 129 

Transportation of tissues, 372 

Transudate, 31, 96, 133 

Transverse colon, 100 

Traumatisms, 15, 72, 80, 81, 98, 99, 106, 
153, 210, 212, 213, 228, 229, 506 

Treatment of post-mortem wounds, 50 

Trematodes, 363 

Trephining, 73, 236 

Treponema pallidum, 335, 369, 387, 388 

Trichina spiralis, 94, 111, 129, 130, 207, 
361, 369, 379, 429, 488, 492 

Trichomonas vaginalis, 359 

Trichophyton tonsurans (the fungus of 
herpes tonsurans), 504 

Trichosis vesicce, 216 

Tricocephalus dispar, 129, 362 

Tricuspid orifice, 117, 148, Fig. 167 

Trigonocephalic skull, 398 

Trional, toxicology of, 463, 467 

Trocar, 38 

Tropacocaine, toxicology of, 468 

Trophic affections of skin, 73 

Trophocephalic skull, 398 

Tropical diseases, see Manson's work on 
this subject 

Trout, cancer of, 108 

Troy weight, 394 

Trypan red, 367 

Trypanosoma, 135, 366; agglutination re- 
action of, 367; T. Brucei, 366; T. disea, 
366; T. Evansi, 366; T. gambiense, 366; 
T. Lewisi, 366 

Trypanosomiasis of animals, 407 

Trypsin, 369 

Tsetse flies, 366 

Tubal pregnancy, see Extra-uterine 

PREGNANCY 



INDEX 



545 



Tubercle bacillus, 341, 354, Plate five; 
finding of, in urine, 348 

Tubercle of Laennec, 342; rabic, 321 

Tuberculin, 52, 318, 344 

Tuberculosis, 48, 68, 70, 81, 99, 106, 111, 
128, 130, 135, 146, 234, 245, 261, 322, 
324, 341, 342, 343, 345, 346, 387, 451, 
493; von Behring's treatment of, 343; 
bile in, 224; bovine, 48, 342, 343; mi- 
croscopic appearance of, 342; miliary, 
100, 148, 162, 344, 352; of adrenals, 191, 
192; of alimentary tract, 346; of ar- 
teries, 152; of bladder, 348; of bone, 
275, 278, 350; of brain, ^ 267, 352; of 
dura, 244; of genito-urinary system, 
347; of heart, 144, 148; of intestines, 
354; of joints, 278, 350; of kidneys, 214, 
347; of larynx, 158, 492; of liver, 224, 
226, 230, 347, 349; of lungs, 163, 168, 
169, 217, 283, 339, 344, 492; of lymph- 
glands, 155, 207, 351; of mammary 
gland, 352; of meninges, 493; of mes- 
entery, 173; of nose, 156; of ovaries, 
219; of oviducts, 218; of pancreas, 231, 
232; of parotid glands, 274; of pericar- 
dium, 110, 111; of peritoneum, 174; 
of pia mater, 352; of pleura, 349; of 
prostate, 348; of respiratory tract, 344; 
of serous membranes, 349; of skin, 48, 
52, 72; of spinal cord, 352; of spleen, 
347, 349; of sternum, 105; of stomach, 
346; of testicles, 222, 348; of thoracic 
duct, 208; of tonsils, 158; of trachea, 
124; of ureters, 198, 348; of uterus, 
220; of vein, 155 
Tuberculous wart, 48, 52 

Tumor (see also the names of the various 
forms of tumors, and of the parts and 
organs), 82, 87, 104, 105, 124, 130, 155, 
218, 494, Plate four; cells of, in blood, 
134; of adrenals, 191; of appendix, 185; 
arteries, 152; of bladder, 216; of bone, 
287; of brain, 243, 267, 352; of breast, 
70, 494; of carotid body, 125; of dura, 
244; of eye, 85; of Fallopian tubes, 
218; of female genital organs, 494; of 
gall-bladder, 206; of heart, 148; of intes- 
tines, 183; of joints, 287; of kidney, 
212, 214, 215; of larynx, 158; of 
liver, 501; of lungs, 169; of lymph- 
glands, 139; of mediastinum, 112; of 
mesentery, 173; of muscles, 94; of nasal 
passages, 156; of neck, 75; of oesopha- 
gus, 124, 200; of ovary, 502; of pan- 
creas, 207; of parathyroids, 108; of 
peritoneum, 172; of salivary glands, 
274; of skin, 73, 494; of skull, 236; 
of spinal cord, 267; of spleen, 130; of 
stomach, 201; of testicles, 222; of thy- 
roid, 108; of urethra, 79; of uterus, 219, 
502; of vagina, 221; of veins, 155; of 
vulva, 78; polypoid, 99 
Tumor albus, 351 



Tunica vaginalis, hemorrhage in, 222 

Turbinates, absence of, 156 

Turmeric paper, 41 

Turpentine, removal of odor from hands 

by, 47; toxicology of, 32, 210, 212, 460 
TV, 343 

Twin pregnancy, history of, 294 
Twine, 40, 42, Fig. 52 
TX, 343 

Types of skull, 397 
Typhoid bacilli, 215, 222, Plate five; fever 

70, 93, 100, 119, 128, 129, 130, 135, 15l! 

157, 175, 178, 215, 222, 261, 264, 283, 

353, 359, 491; spine, 355 
Typhus fever, 48, 130, 137, 139, 157, 175, 

356, 388, 491 
Tyrosin, 68 

U 

Udder, examination of, 408, 409, 430 

Ulcer, 72; atheromatous, 150; diph- 
theritic, 78; of colon, 186; of cornea, 
84; of duodenum, 178; of heart, 48^ 
145; of intestines, 182, 347; of larynx, 
158; of oesophagus, 124, 200; of stom- 
ach, 98, 100, 500; of vagina, 221; 
syphilitic, 124; tuberculous, 100, 124, 
347; tuberculous, how differing from 
typhoid, 354; typhoid, 100; typhoid, 
how differing from tuberculous, 354; 
typhoid, in Meckel's diverticulum, 355 

Ulcus molle, 336 

Ultraviolet microscope, 368, 388 

Umbilical cord, diseases of, 101, 143, 
445; examination of, 291, 396, 445, 
488, Figs. 164, 168 

Umbilicus, 15, 78, 216, 291, 408, 409, 
Figs. 164, 168 

Uncinaria Americana, 362; U. duodena- 
lis, 362 

Uncinariasis, 362 

Undertakers and postmortem, 4, 7, 9 

Undulant fever, 323 

Unguents, antiseptic, 46 

Unguentum Crede, 51 

United States Army, autopsies in, 22; 
post-mortem instruments used in, 43 

United States Marine - Hospital Service, 
306; autopsies in, 23 

United States Navy, autopsies in, 22; 
post-mortem instruments used in, 43 

Urachus, 78, 216, Fig. 164 

Uremia, 31, 73, 127, 130, 134, 261, 451, 464 

Uranium, salts of, toxicology of, 467 

Urate, ammonium, 211, 217; sodium, 
141, 211, 217, 293 

Urea, 130, 211, 217 

Ureter, abscess of, 193; absence of, 
215; accidental tying of, 193; ad- 
hesions of, 193; calculus of, 193, 215; 
Coccidia in, 366; cysts of, 215; Dis- 
toma haematobium of, 193, 215; double, 
193, 215; Echinococcus in, 215; epi- 



546 



INDEX 



Ureter (continued) 

thelial cells of, 193; examination of, 
15, 17, 187, 188, 193, 194, 195, Fig. 
122; examination of, in animals, 414, 
419,430; hemorrhage of, 193; measure- 
ments of, 404; papillary fibroma of, 
193; parasites in, 215; polyps of, 215; 
stenosis of, 215; stricture of, 193; tuber- 
culosis of, 193, 348; twists of, 193, 210 

Urethra, diseases of, 33, 79, 502; ex- 
amination of, 15, 17, 404, 430, 486 

Urethritis, 79, 319 

Urethrorectal fistula, 79 

Uric acid, 141, 142, 189, 211, 214, 217, 
293 

Urinary tract, diseases of, 142, 502 

Urine, 141, 19a, 217, 487; acetone in, 
233; beta-oxybutyric acid in, 233; 
black, causes of, 217; diacetic acid 
in, 233; effect of poisons on, 466; frog 
test for strychnine in, 193; glucose 
in, 233; of new-born, study of, 293; 
securing of, for examination, 193, 393; 
sediments in, 217; specific gravity of, 
233; tubercle bacilli in, 348; typhoid 
bacilli in, 353 

Urinometer, 39 

Urobilin, 224, 225, 467 

Urobilinogen, 224 

Uropygium, 429 

Urticaria, 71, 73 

Usual causes of death, nomenclature, 
complications, and synonyms of, xxx, 
p. 491 

Utensils in postmortems on large domes- 
tic animals, 407 

Uterus, adenoma of, 219; adenocystoma 
of, 219; amyloid degeneration of, 219; 
atresia of, 219; atrophy of, 219; bac- 
teria in, 220; cancer of, 219; congenital 
abnormalities of, 219; deciduoma malig- 
num of, 219; dermoid cysts of, 220; 
examination of, 15, 17, 195, 486, Fig. 
107=116; examination of, in animals, 
430; fibroma of, 219, 220; foreign 

. bodies in, 221; hsematoma polyposum 
of, 219; hemorrhages of, 142, 220, 
502; hyaline degeneration of, 220; 
hydatiform moles of, 219; hypertro- 
phy of, 219; hypoplasia of, 219; infan- 
tile, 219; leiomyoma of, 219; lipoma 
of, 219; measurements of, 406; myo- 
fibroma of, 219; myoma of, 219, 220; 
myosarcoma of, 219; rupture of, 220; 
stenosis of, 219; subseptus of, 219; 
thrush fungi in, 220; tuberculosis of, 
220, 348; tumors of, 219, 502; weight 
of, 221, 394, 406 

Uterus bicornis, 219; U. bicornis duplex, 
219; U. bilocularis, 219; U. bipartitus, 
219; U. cordiformis, 219; U. didelphys, 
219; U. septus duplex, 219; U. uni- 
cornis, 219 



Vaccination, 70; for smallpox, 333; for 
tetanus, 341 

Vaccinia, 356 

Vagabondism, 68 

Vagina, diseases of, 221, 314, 334, 348; 
examination of, 15, 17, 46, 295, 486; 
examination of, in animals, 420, 430 

Vaginitis, 319 

Vagus, pressure on, 159 

Valentine knife, 35, Fig. 1 9 

Valsalva, sinus of, aneurism of, 146, 154 

Valve, ileocecal (Gerlach's), 180; of pul- 
monary artery, 117 

Valves, cardiac, diseases of, 126, 146, 
147, 228; competency of, 116; ex- 
amination of, 15, 115, 144, 419, Figs. 
76=85 

Vapors of nitric acid, etc., inhaled, toxi- 
cology of, 465 

Varicella (chicken-pox), 71, 72, 311, 356, 
388 

Varicocele, 78, 155 

Varicose veins, 157 

Variola, see Smallpox 

Varioloid, see Smallpox 

Varix, 154, 155, 222 

Varnish, 45 

Vasa deferentia, 17 

Vaselin, 45, 46 

Veins, azygos, 17, 208; coronary, 113, 
118; diseases of, 136, 137, 154, 155, 
498; examination of, 122, 256, 487; 
inflammation of, see Phlebitis; pul- 
monary, Fig. 80 ; oesophageal, 124; of 
Thebesius, 118; ovarian, 220; portal, 
154; spermatic, 155; suppuration of, 
154; thrombosis of, 154; traumatism 
causing diseases of, 154 

Velum palati, 15, 17, 123, 418, 430, 485, 
Fig. 91 

Vena cava, 15, 16, 17, 207, 208, 418; 
examination of, in animals, 413, 415, 

418, 428, 430 

Ventricles of brain, examination of, 16, 

483 
Ventricles of heart, diseases of, 113, 142, 

144, 148; examination of, 15, 114, 117, 

419, Figs. 81=85 
Ventricular septum, 118 
Veratrine, toxicology of, 461, 463 
Veratrum viride, post-mortem rigidity 

in poisoning by, 59 ' 
Vermiform appendix, see Appendix ver- 

MIFORMIS 

Vernix caseosa, 489 

Verruca, 73 

Vertebrae, caries of, 308 

Vertebral column, diseases and injuries of, 
253, 283, 308, 355, 441; examination 
of, 16, 253, 482, 486, Figs. 154-158 

Vertigo, 257 



INDEX 



547 



Vesiculse seminales, 17, 348 

Veterinary postmortems, xxv, p. 407 

Viability of child, how determined, 293, 
443, 444, 488 

Vibrio cholerce, 388 

Vienna method of exenteration of ani- 
mals, 416 

Vienna, postmortems at, 7, 15, 435 

Vincent's angina, 313 

Violence, external, forms of, 506 

Virchow, 8, 14, 23, 27, 43, Fig. 201 

Virchow's method of sectioning brain, 
246, Figs. 141-147; red atrophy, 229 

Virulence of organisms, 49 

Vise, 38 

Vitiligo, 69, 71 

Vocal cords, 123, 124, 157, 158, 270, Fig. 
93 

Volatile oils, effect of, on urine, 466 

Volvulus of omentum, 172; of sigmoid, 
101 

Vomica (cavity) 

Vomit, luminosity of, 465 

V-shaped incision, 118 

Vulva, diseases of, 78, 336; examination 
of, 17 

Vulvitis, 324 

Vulvovaginitis, 325 

W 

Wart, 48, 73, 78; anatomic, 51, 52; syph- 
ilitic, 336 

Warthin's autopsy-protocols, 19 

Water, distilled, 41; percentage of, in 
body, 396; use of, in cleansing parts, 
10, 13, 29 

"Water gas," toxicology of, 473 

Waxy degeneration in typhoid fever, 
92, 353 

Weigert's fibrin stain, 375 

Weights (see under the various organs 
and parts), 68, 138, 221, 243, xxiv, p. 
394 

Wens, 73 

Wetherill's haemoglobin scale, 126 

Wheat rust, 432 

Whetstone, 39, 42, Fig. 21 

Whip-worm, 362 



Whitlows, 48 

Whooping-cough (pertussis), 130, 157, 325, 

388, 491 
Widal test, 134, 181, 353, 354 
Williams case, 462 
Winkler vs. Hawkes, 6 
Winslow's test, 54 
Wire, platinum, 41 
Wire saw, 35, Fig. 163 
Wiring in cases of aneurism, 154 
Wirsung's canal, 199 
"Wish-bone," 429 
" Wooden tongue," 306 
Woodhead's method of examining ear, 

272 
Worms, intestinal, 98 
Wound, 2, 15, 16, 41, 46, 48, 49, 50, 

62, 63, 75, 111, 112, 146, 341, 481; 

bullet, Plate six 
Wound-infection, 52 
Wrisberg's ganglion, examination of, 

290, Fig. 74 



Xanthine, 214, 217 

Xanthoma, 73 

Xiphoid cartilage, 98 

Xiphopagus, 77 

X-rays, anatomic wart treated by, 52; 
cancer caused by, 455; determina- 
tion of the existence of life by, 54; in 
determining arsenic in stomach, 471; 
legal aspects of, 455; sterility caused 
by, 222, 455; study of bone lesions 
by, 62, 275 

Y 

Y incision, 90 

Yaws, 317 

Yellow atrophy of liver, acute, 106, 173, 

357 
Yellow fever, 48, 388, 407, 492 



Zenker's degeneration, 92, 355; fluid, 375 
Zinc chlorid for hardening brain, 252 
Zinc salts, toxicology of, 465, 473 
"Zuckerguss" liver and spleen, 102, 223 



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